Yale Global Health Review Vol 4 No 2 by Yale Global Health Review

WINTER 2017

Delhi’s Air Pollution and its Effects on Children’s Health By Rebecca Slutsky p. 25

Anoop Kumar, Flickr

VOL. 4, NO. 2

LETTER FROM THE EDITORS WINTER 2017 VOL. 4, NO. 2 Dear Readers, We are excited to share with you the first issue from our new Executive Board. This issue takes us on a journey from our home here in the United States to hospitals in China to secluded forests in Africa. Our writers both figuratively and literally travelled the world to bring you this glimpse into some of the most pressing global health issues of our time. We hope that our team’s efforts will serve as a platform to promote change and engage the Yale community in meaningful discussions about global health. In this issue, our feature article delves into the effects of pollution in India on the health of the country’s most vulnerable citizens: children. This issue also addresses topics such as fracking in the United States, ophthalmology in Ghana, viral load monitoring in Uganda, female genital mutilation in Africa and sandbar cropping in Bangladesh. These articles provide a snapshot of the unique challenges that different countries and regions face today, challenges that necessitate collaboration among a wide range of health-related fields. None of this would have been possible without the incredible work by the members of our Executive Board. We are humbled by the commitment our board has displayed throughout this semester, tirelessly working to publish pieces that critically examine the major issues affecting people throughout the world. But we also want to emphasize that our board is more than just our writers. We’d also like to thank our production and design team as well as our business team for their work in keeping this publication running. Most of all, we would like to thank you, our readers, for your interest in our work, as you are the sources of innovation and creativity that will drive global health movements in the years to come. For more global health, visit our blog at yaleglobalhealthreview.com. Better yet, to get involved, set us an email at yaleglobalhealthreview@gmail.com. All the best, Jessica Schmerler & Kai DeBus OUR TEAM Editors-in-Chief Jessica Schmerler Kai DeBus Senior Editors Cassandra Lignelli Lauren McNeel Ohvia Muraleetharan Rebecca Slutsky Associate Editors Anabel Starosta Hannah Krystal Minh Vu Sarah Householder Copy Editors Annabelle Pan Dhikshitha Balaji Katarina Wang Krista Chen Nancy Lu Senior Online Editor Holly Robinson YALE GLOBAL HEALTH REVIEW

Online Editors Al Nurani Carlin Sheridan Devyani Aggarwal Dhikshitha Balaji Production & Design Team Eileen Norris Holly Zhou Maheen Zakaria Michelle Cheng Business Team Ahmad Hassan Catherine Xue Dhruva Gupta Spencer Briney Staff Writers Akhil Upneja, Akila Shanmughan, Colin Hemez, Elijah Rami, Emma Phelps, Holly Robinson, Matthew Pettus, Nealie Ngo, Sarah Spaulding

ABOUT US The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus. Our goal is to bridge scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors. The YGHR is a hub for discussion and engagement on all issues relevant to global health – in print and online, at Yale and beyond. SPONSORS We would like to thank the Yale Global Health Leadership Institute, Yale Global Mental Health Program, Yale China, the Yale School of Public Health Admissions Department & the Yale Undergraduate Organizations Committee for their support.

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CONTENTS p. 3 p. 7 p. 11 Thomas Schoch

ON THE COVER Delhi’s Air Pollution and its Effects on Children’s Health By Rebecca Slutsky p. 25

p. 16

HEALTH PERSPECTIVES

p. 19

FIELD WORK

p. 22

The Global Health Implications of a Nuclear War By Sarah Spaulding

Inside the Doctor-Patient Relationship of China By Sophia Yin

MENTAL HEALTH

PTSD in Children and Adolescents: Equivalent Exposures, Distinct Diagnoses By Holly Robinson

p. 35

p. 39 p. 43 NIAID

GLOBAL HEALTH TODAY What Virus Evolution Can Tell Us About the Next Epidemic By Colin Hemez p. 45

p. 49 p. 53

FIELD WORK

Bringing Sustainable Healthcare to UnderResourced Populations By One World Health

GLOBAL HEALTH TODAY

Female Genital Mutilation: A Global Health Perspective By Jessica Schmerler

INTERVIEW

Seth Wanye on Eye Care in Developing Countries: A Vision for a Brighter Ghana By Kai DeBus

GLOBAL HEALTH TODAY

Colonialism, Civil War, and Ebola: Historical Perspectives on Contemporary Healthcare in Sierra Leone By Elijah Rami

Simon Fraser University

HEALTH POLICY Is Fracking Safe? By Emma Phelps p. 29 FIELD WORK

HIV/AIDS and Viral Load Monitoring in Uganda By Isla Hutchinson Maddox

SUSTAINABLE DEVELOPMENT

Transforming the Narrative of Bangladesh’s ‘Mini-Deserts’ By Minh Vu

HEALTH POLICY

Healthcare: Is There Only One Correct Answer? By Elizabeth Li

HEALTH PERSPECTIVES

A Spoonful of Sugar Helps the Medicine Fight Cancer By Gracie Jin

FIELD WORK

Bringing Sustainable Healthcare to Under-Resourced Populations: Field Experiences from OneWorld Health

lobal health is a rapidly growing field, and the need to improve access to high-quality care in developing countries has become increasingly apparent. Various charitable organizations, missionaries, and NGOs have attempted to supplement the healthcare provided by the government with short-term relief efforts. However, there is still a desperate need for everyday, ongoing care for patients in the developing world. OneWorld Health (OWH) was developed with the goal of decreasing that gap by providing long-term, sustainable healthcare in the communities that need it most. The organizationâ&#x20AC;&#x2122;s vision is to see impoverished communities take ownership in a sustainable healthcare model and empower them to bring about longterm change and tangible improvements in their health and quality of life. OWH has developed a model that provides affordable healthcare to the communities that need it most and does not require ongoing support to keep the doors open. Furthermore, local people in the community staff each medical center, which encourages community engagement. Each OneWorld Health medical center offers a full scope of healthcare services to the community, delivered by trained nationals and offered at a price point that is affordable to the overwhelming majority of the population. Patient fees

offset the costs of running the clinic, eventually meeting or exceeding the total monthly operating costs. This model has proven extremely successful, and this year more clinics will be opened and more staff will be trained in advanced medical procedures. So what is it like to be a part of this organization? Three key members of the leadership team explain their experiences and perspectives on working in the field. Aaron Stroud-Romero, Vice President of Field Operations OneWorld Healthâ&#x20AC;&#x2122;s innovative social enterprise model places it squarely between the overwhelmed and understaffed public health system and the expensive private health system. Though there are a few others working within this niche market, they are often charity hospitals that require continual financial support. By contrast OneWorld Health aims to provide high quality, affordable care, without ongoing financial support for operations. When I first heard about OneWorld Health in 2013, it all sounded too good to be true. Their first medical facility in Masindi, Uganda, had managed to become operationally sustainable in its first year. With such success, they built an inpatient department, which also became sustainable in about a year. The maternity ward, labor and delivery suite, and operating theatre were just over a year old and were on their way to sustainability. At this point, I had spent nearly four and a half years working in the health sector in Sub-Saharan Africa and had never heard of such a thing. I spent two and a half years working for OWH as the Regional Director in Uganda. In that role, I worked with our national leadership staff at each facility to ensure that our business model was sound and that the quality of care met the highest standards. The previous Regional Directors were always based at the facility in Masindi, but my position was to be based in the capital, three hours away. This transition was done intentionally to allow the national leadership team to take even greater ownership of the project. We certainly faced challenges, but our team has shown incredible perseverance in the midst of struggles. Their growth in both hard and soft skills is the kind of leadership that we at OneWorld Health seek to foster with our national teams everywhere. In my current role as Vice President of Field Operations, I have the privilege to work with our Regional Directors in both Uganda and Nicaragua to develop and implement our growth plans, while also ensuring that our business model is working in each facility.

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and peoples meriting a quick glance at the news or a prayer at the dinner table, but not much more. Nor was I interested in medicine at the time, and while I cared deeply about serving others, I figured that local church and charity work was about as far as that passion would go. I definitely never imagined my life and work would one day be dedicated to global health.

The site of OneWorld Health’s Clinica Integral-Sebaco, which opened in Nicaragua in July 2015.

So what happened? Well, I discovered Jimmy Buffett. I know, I know, it’s silly—this hokey niche artist singing poorly-written songs about Latin tourist traps and Caribbean beach bums, but the music was, for me, a window into a world I had never experienced before. I had to see it with my own eyes. In college, I signed up for a summer internship with a development organization in the Dominican Republic, mainly because it was near the ocean (which I had never seen before) and sounded exotic, but manageable.

In my last three years of working with OneWorld Health, I have been amazed at how much can be done, with relatively little financial input. By working with the community, rather than for them, we have empowered community members to see the value in their health. Community members recognize the difference in the quality of care, our consistency and accountability to them as patients, and the hospitality and patient care that each of our staff provides.

in Masindi, we are prepared to pay.” Our hope is that these expectations will start to become normal, that private and public facilities will begin to hold their staff accountable, improve their patient care, and create real value for patients, generating an impact far beyond the number of facilities we can build or patients we can treat. OneWorld Health

In those rolling green mountains and pastel-colored palm houses, I very quickly got the education of a lifetime. Suddenly, I realized that Latin America and the Caribbean were so much more than the clichés that drew me to them. They were, instead, places of vast riches and poverty, joy and suffering, and were made up of a myriad of fascinating cultures and compelling histories that I couldn’t even scratch the surface of in just one summer. I was forever hooked.

To be clear, despite six successful years of operation and growth, we continue to face challenges. There are a whole host of cultural challenges that we face–reliability and timeliness, honesty and transparency, and customer service. Leadership at each of our facilities sets an incredibly high bar and holds their teams accountable. This is not always an easy task, but the community has certainly come to appreciate and expect it. I remember sitting in a community meeting before we built our second facility about an hour from Masindi. The community leaders and local church members were so excited about the medical facility we were going to build. While I was obviously encouraged by their enthusiasm, I began to worry that they thought we were going to be a free medical care provider. I hesitantly broached the subject and waited for their response. The community members let out a little laugh, and one of the leaders stood and said that they were well aware of the financial obligation, saying “if you are bringing the kind of care that we have seen

Whenever I get the chance, I take a few minutes and just sit down in the lobby of OneWorld Health’s clinics here in Nicaragua. On a normal day, I sit next to young mothers with feverish babies, older ladies with swollen feet checking their blood sugar, teenage soon-to-be mothers anxious about their first ultrasound, and day laborers who come in for a quick stitching-up before carrying their machetes back out to the sugar cane fields. I’m not there as a patient (usually, at least), but as a learner. Hearing their stories, I am amazed at the challenges they bravely face every day, and am humbled by the opportunity to be part of their story. Afterwards, I’m always left with the same question: “How did I end up here?” I’ve found it’s a common sentiment from expat and development communities; we all arrived at wherever it is we find ourselves from the strangest places, it seems.

OneWorld Health

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TJ McCloud, Regional Director of Central America

As for me, a Midwestern boy, I didn’t grow up speaking other languages or traveling to faraway places. My world was pretty small, with international events

Soon, I was successfully coaxing my Oklahoma drawl into Spanish conversations with people I never imagined I would befriend or work alongside. I learned of the struggle that is daily life for most of the world, and suddenly found new appreciation for how access to even basic health care saves lives and helps communities and local economies develop and become more productive for the people who live there. For me, working in global health is the best way I’ve found to blend my love of people and culture, history and development. When I was unsure about what discipline to focus on in development work, a mentor pointed me towards global health and said, “people who die from easily treatable illnesses don’t ever get a chance to develop their communities.” So, here I am, Regional Director for OneWorld Health’s Central American projects. My family and I live in Managua. I spend most of my time here in the capital at our central office, coordinating

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I travel regularly in the shadow of volcanoes and lakes, through cane fields and banana plantations, sometimes spotting howler monkeys or sloths in the trees as I visit our three fixed clinic sites and our mobile clinic, all My temptation to reof which function primarily in spond with this data is spawned I rural areas. from an altruistic place. It is an attempt confess, I still

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OneWorld Health’s legal, financial, and operational challenges (there’s always a new hurdle in this business). I love being in a position to develop and nurture our service-oriented organizational culture, and our quickly-growing list of projects and programs. More than anything, however, I relish the opportunity to visit a project each week to experience, learn from, and assist in the important work our staff does, day in and day out. I travel regularly in the shadow of volcanoes and lakes, through cane fields and banana plantations, sometimes spotting howler monkeys or sloths in the trees as I visit our three fixed clinic sites and our mobile clinic, all of which function primarily in rural areas. At the time of this writing, we have a staff of 25 full-time and 30 part-time healthcare and support professionals, of which I am the only North American. Sitting in that clinic lobby, I often wish I had the medical skills to personally treat these “stakeholders” next to me, but I’m proud to have a team of local professionals that I can rely on and learn from.

kind of like Jimmy Buffett, and every once in a while you might find me on a Nicaraguan beach, but my heart and hands love this work and people so much more than I ever would have imagined in my previous life. I am constantly grateful to be able to support OneWorld Health’s local providers as together we build high-quality, low-cost, sustainable healthcare for generations to come.

Michael O’Neal, Executive Director As I begin to formulate a response to the statement, “Tell me about your experience working in global health,” I am tempted to reply with a myriad of numbers. I am tempted to rattle off statistics that are, and have been, at the forefront of my mind for years, such as the under-five mortality rate of 54.6 per 1,000 live births in Uganda.1 Or the fact that public health expenditure in the same country is a dismal 1.8% of its GDP.2 Or the sad reality that in Burundi, there is only 1 physician for every 35,000 people.3

to quickly and succinctly communicate the salient need for the world to concentrate on responding to healthcare needs in the developing world. It is an attempt to create a framework for the listener to relate to the harshness of life that is the reality for the roughly 1 billion people living under the international poverty line ($1.90/day) around the globe.4 However, as I try to get a bigger perspective, I recognize that my knee-jerk reaction to respond with statistics is a synthetic attempt to convey my message. I recognize that I am not doing the listener, my East African and Central American friends, or myself justice by responding quantitatively and focusing only on the despair that exists in these contexts. Because the one thing that all of those numbers have in common is that they represent a person: a beautiful life with a name and a story, with real tears, real smiles, real hopes, real dreams and most of all, real life. The lives of so many of these individuals have shaped me into the man I am today and continue to shape my future and the future of my family.

OneWorld Health Since opening their first medical center in January 2011, OneWorld Health has provided medical care to nearly 150,000 patients.

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OneWorld Health A staffworker examines a patient in the waiting room at OneWorld Health’s Bulima Ktara Medical Center in Uganda, which opened in February 2016.

I currently have the privilege to serve as the Executive Director for OneWorld Health, a global health organization that exists to provide quality, affordable care to those in need. My role with OWH provides me with an opportunity to bridge the gap between my family, friends and colleagues in the United States to my family, friends and colleagues in East Africa and Central America. I have the privilege of working with our host country staff to navigate the complex healthcare infrastructure and work alongside them to develop longterm strategies. I work collectively with our team to develop culturally-relevant and sustainable projects that seek to empower individuals and communities through quality healthcare. As I have had the privilege to interact with people from Nicaragua to Burundi, each interaction has tinted the lens through which I see the world. I have discovered a common thread in all my experiences: we are all more similar than we are different.

that could only happen by stepping out of my comfort zone and experiencing the harsh realities of life. We have shed tears over the heart-wrenching loss of life. We have shared countless frustrations about the brokenness of our world that leads to the systematic dysfunction that plagues the majority of healthcare systems around the globe. We have rallied together around late night calls or knocks on the door of mothers pleading for help to ease the suffering of their children. And in each of those moments, I have learned that we are more alike than different.

Over the years, I have developed deep friendships with folks that I have nothing in common with. We were born and raised on opposite ends of the earth, in different cultures and with different life experiences. Even so, these friends have become family. We have shared in one another’s pains and joys. We have tirelessly worked to see small changes take hold in the health of the community. We have worked together to take the next baby step in improving health for their families. And in all of it, I have learned that we are more alike than we are different.

One patient’s story that is still emblazoned on my mind and heart to this day is that of a 6-year-old boy named Eddie from the Uganda bush, who, by all accounts, had no chance of survival. But through the unwavering efforts of our Ugandan clinical staff that worked tirelessly day and night and fought for him, he beat all odds and is now a healthy 11-year-old boy. And, undoubtedly, also a hero of mine. And as I share in the joy of his life and celebrate the brilliant and dedicated clinicians that saved it, I have learned that we are more alike than different.

Many people who are represented by the statistics above have less than a second grade education but have challenged me intellectually, spiritually and philosophically in ways

In my story, one that was prompted by a deep calling to serve the least advantaged of the world, it has turned out that the “least advantaged” have given me ex-

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I have shared in joy where life has been given a second chance and communities have been transformed. This transformation was not the result of Western innovation or ingenuity, but the simple provision of a space for the community to share their vision for their community and respond to their needs. I have learned that we are more alike than different.

ponentially more than I have left behind. My hope is twofold. First is that, as OneWorld Health continues to invest in the communities where we work, a greater impact can be made and each medical center will exist long after we are gone. And second, I hope that our partner communities will continue to allow me to learn and grow from our partnership, as I am forever grateful for the lessons I have learned from my friends around the world. Being at the forefront of global health crises has given me the perspective and humility to continue to do this work, and I am optimistic about what we can achieve in the future.

www

OneWorld Health currently has four permanent clinics and one mobile clinic in Nicaragua and Uganda. For more information, please visit oneworldhealth.com

GLOBAL HEALTH TODAY

Female Genital Mutilation:

A Global Health Perspective

Arts at LSE

magine a procedure in which a child is cut in a highly personal area in a highly painful manner, with no say in the matter whatsoever. Associated with this procedure are complications ranging from infection and bleeding all the way to death. From many perspectives, this procedure is a violation of the childâ&#x20AC;&#x2122;s basic human rights. However, this procedure is condoned in and is part of the accepted cultural practices in 30 countries in Africa, the Middle East and Asia.1 Known as female genital mutilation (FGM), it has been performed for millennia and is one of myriad examples of gender inequality issues plaguing global health today.

By Jessica Schmerler

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Russell Watkins/UK Department for Internal Development

in the journal The Lancet examined birth outcomes in women who underwent FGM and showed that women with Type 3 FGM were 70% more likely than women who had not undergone FGM to suffer from postpartum hemorrhage. Furthermore, the findings indicated that FGM leads to an extra one to two infant deaths per 100 births, likely due to the increased risk of difficulties with delivery.3 In addition to these physical harms, long-term consequences include PTSD in girls old enough to remember being cut, and the shame and depression associated with complications. The United Nations Population Fund (UNFPA) compiles and publishes interviews with victims of FGM, including the heart wrenching story of Zainab, a girl subjected to Type 3 FGM at age 8: “Another girl was infibulated and she died because of the operation. We were so scared and didn’t want to suffer the same fate. But our parents told us it was an obligation, so we went. We fought back; we really thought we were going to die because of the pain… We were lucky, I suppose. We gradually recovered and didn’t die like the other girl. But the memory and the pain never really go away.”2 A HISTORY OF FGM

Alimatu Dimonekene, FGM prevention caseworker and trainer for Newham One Stop Shop, speaking at the opening session of the Girl Summit 2014.

WHAT IS FGM? FGM, formerly referred to as female circumcision, involves the removal of all or part of the female genitalia and is typically carried out on girls before the onset of puberty. The World Health Organization (WHO) classifies FGM procedures into four categories based on the extent of mutilation: Type 1, clitoridectomy, involves total or partial removal of the clitoris; Type 2, excision, involves total or partial removal of the clitoris and labia; Type 3, infibulation, involves narrowing of the vaginal opening by creating a covering seal using existing tissue; and Type 4, which includes all other non-medicinal procedures harmful to the female genitalia.

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Despite the medical ramifications, which were likely far more severe and common before the advent of modern medicine, FGM is deeply embedded in various cultures, dating back more than 2000 years. The exact origins of FGM are unknown, though examples of practices akin to FGM have been traced to ancient Egypt, Ethiopia and Greece. The first literary mention of FGM can be found in the writings of Greek geographer Strabo documenting his visits to Egypt in 25 B.C.E. The procedure was again described in the writings of the celebrated second century C.E. Greek physician, Galen. In ancient times, it is believed that FGM was developed as a method to tame the excessive sexual desires of women.4 After millennia of refining the practice of FGM, the procedure remains perilous to women’s health by medical standards. Cutting is typically performed by midwives in unsterile conditions with non-surgical instruments such as knives and razor blades, using little to no anesthesia. Furthermore, in countries where FGM is not condoned by medical authorities, doctors are trained to inform patients of the health risks associated with FGM but are not trained to and are banned from performing the procedure. As a result, women living in in-

After millennia of refining the practice of FGM, the procedure remains perilous to women’s health by medical standards.

The WHO reports that “FGM has no health benefits, and it harms girls and women in many ways.”1 Harms associated with FGM, most frequent and severe in Type 3 FGM, can be both immediate and long-term. Immediate complications include pain, infection, bleeding and sepsis, all of which can be fatal in severe cases. Long-term complications include difficulty in childbirth, anemia, incontinence, sexual dysfunction and increased risk for contraction of HIV/AIDS or other sexually transmitted infections.2 A 2006 WHO study published

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dustrialized countries whose cultures promote FGM in spite of national regulations often undergo the procedure in secret, putting themselves at further risk.5 The preservation of this practice stems from both religious and sociocultural factors. Dr. Loretta Kopelman, former chair of the Department of Medical Humanities at the East Carolina University School of Medicine, postulated four primary reasons: preservation of group identity; maintenance of cleanli-

ness and health; preservation of virginity and family honor and the prevention of immorality; and the furthering of marriage goals and enhancement of sexual pleasure for men.6 In many societies that practice FGM, marriage is essential for the establishment of social and economic stability, and as such it is difficult to oppose the institution of FGM due to its close ties to a woman’s marriageability.7 In many parents’ minds, FGM is not harming their daughter but rather ensuring her future.4 Regardless of opinion on the matter, FGM and its history run deep within the feminine culture in the 30 nations where it is practiced. For example, in Sierra Leone, the practice of FGM occurs within the Bondo society, also known as the Sande, an all-women society to which nearly 90% of Sierra Leonean women belong. It serves as a community for women to escape their household responsibilities and seek out the comfort and guidance of other women, and as such, FGM in Sierra Leone has proven particularly challenging to oppose. One girl recounted her story after being cut in a Bondo ritual at age 12: “My mum… said they have bundu [Bondo] societies throughout Sierra Leone and the societies are not entirely bad – they do have a good meaning behind them… I always wondered about what happened to the girls I spent those two weeks with, so I asked my mum. She told me that we missed the fun part of the bundu forest. After the wounds heal, the girls are taught how to do domestic skills

like cooking, washing clothes, ironing and everything that has to do with being a good wife and mother.”8

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The practice of FGM has been viewed as in violaFGM IN THE MODERN WORLD tion of UN Conven tions on women’s The prevalence of the four types of FGM varies across 30 countries in Africa, the Middle rights and East and Asia. The countries with the highest “Even prevalence include Guinea, at 99%, Egypt, at children’s 97%, Mali, at 92%, and Sudan, at 90%. More though culrights. than 200 million women and girls worldwide tural practices 9

have been subjected to FGM in the countries where it is still practiced, with nearly 3 million girls at risk of FGM each year.1

Due to the efforts of grassroots, national and international organizations over the past 40 years or so, FGM has been outlawed in many countries and is considered socially unacceptable in most. Underlying this opposition is the claim that FGM is a fundamental violation of human rights. Furthermore, the practice of FGM has been viewed as a violation of UN conventions on women’s and children’s rights. The practice was first officially conceptualized as a human rights violation at the 1993 World Conference on Human Rights in Vienna. At this conference, FGM became classified as a form of violence against women (VAW), and VAW was acknowledged as falling within the domain of international human rights law.10 Then, in 1997, the WHO, UNICEF and UNFPA issued a joint statement:

Lindsay Mgbor/ UK Department for Internal Development Women from the Zitenga region of Burkina Faso listen to a discussion on Female Genital Mutilation during a visit from UK International Development Minister, Lynne Featherstone.

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may appear senseless or destructive from the standpoint of others, they have meaning and fulfil a function for those who practise them. However, culture is not static; it is in constant flux, adapting and reforming. People will change their behaviour when they understand the hazards and indignity of harmful practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture.”11 Despite this statement nearly two decades ago, FGM persists in certain countries and occurs throughout the world due to immigration. For example, in the United States in 2013, more than 500,000 women and girls were considered at risk for FGM because of what is referred to as “vacation cutting”: American-born children of immigrants from countries where FGM is highly prevalent are brought to their parents’ countries of origin to be cut.12 The efforts to end FGM worldwide have further intensified over the past decade, attempting to extend beyond the legal sphere and into the social sphere. According to UNICEF, “Unless legislation is accompanied by measures to influence cultural traditions and expectations, it tends to be ineffective, since it fails to address the practice within its broader social context.”10 In 2008, ten United Nations agencies signed an interagency statement committing to efforts to eliminate FGM. Then, in December of 2012, the United Nations General Assembly adopted the resolution, Intensifying global efforts for the elimination of female genital mutilations. The resolution calls on individual nations to put into action punitive measures and social movements such as education campaigns to protect the rights of women and girls as well as on the international community to provide financial support to put an end to FGM.13 Along with the opposition to FGM on the legal front, the movement to end FGM has also grown in prevalence among grassroots orga-

YALE GLOBAL HEALTH REVIEW

Michael Ruckl

nizations. One such organization, Equality Now, was founded in 1992 with the goal of protecting the rights of women and girls. For more than two decades, their efforts to end FGM have included advertisement campaigns and videos shared through major international media sources such as BBC and the New York Times, letter-writing campaigns to promote the passage of anti-FGM legislation, blog posts and, starting in late 2016, a compilation of stories from FGM survivors.14 Equality Now’s partnership with the Home Office of the UK government led to the creation in 2012 of the “Health Passport,” an information sheet available in 11 languages designed to be carried in a girl’s passport that details the criminal status of FGM in the UK and the support available to provide protection against FGM pressures in foreign countries.15 Equality Now also partners with a number of other influential anti-FGM organizations such as Safe Hands for Girls and The Girl Generation. Safe Hands for Girls was founded in 2013 by Jaha Dukureh, a Gambian FGM survivor who was named to Time magazine’s Top 100 Influential People in 2016 for her work.16 The Girl Generation is a social change communications platform that connects and supports local grassroots organizations opposing FGM around the world.17 These organizations are only three of the many organizations working tirelessly to oppose the existence of FGM as a social norm in the hopes that someday it may be eliminated entirely.

and is as such an important global health issue. Efforts to oppose FGM date back to the 1920s and have intensified in recent decades. The anti-FGM movement has advanced as far as seemingly possible on the international legal level but still has far to go on the sociocultural one. It is so deeply entrenched within certain cultures that prohibition and punishment have little effect. Although generational analyses have shown that the practice of FGM has been steadily decreasing since the 1970s with the advent of international legislative initiatives, this progress has been slow. According to UNICEF, “Findings suggest that efforts to end the practice need to go beyond a shift in individual attitudes and address entire communities in ways that can decrease social expectations to perform FGM.”10 In other words, to make measurable progress toward the elimination of FGM in the remaining 30 countries where it is heavily practiced will require the mobilization of the international community as a whole to affect the beliefs of individual communities. FGM will not be eliminated by teaching individuals to not cut their daughters but rather by encouraging them to not want to do so.

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CONCLUSION Female genital mutilation is a violation of human rights, particularly those of women and children. It is an operation performed for non-medical reasons but carries with it devastating medical complications

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Jessica Schmerler is a senior in Jonathan Edwards College majoring in Molecular, Cellular & Developmental Biology (Int.), Neurobiology Track. She can be contacted at jessica.schmerler@yale.edu.

Kai DeBus

INTERVIEW

GHANA:

Dr. Seth Wanye on Eye Care in Developing Countries

eth Wanye (MD, PhD) is an ophthalmologist in Ghana, a lower-middle income country in West Africa. His focus is to make healthcare, specifically ophthalmic care, more accessible to people in remote areas. In 2005, he partnered with Unite for Sight, a non-profit based in New Haven, Connecticut, to expand his ability to reach marginalized people and perform sponsored cataract surgeries. The Yale Global Health Review had an opportunity to sit down with Dr. Wanye and discuss his work in Ghana, gaining insight on both the importance of ophthalmology and the challenges associated with practicing medicine in resource-limited settings.

By Kai DeBus

Why did you want to become an ophthalmologist [My decision to become an ophthalmologist] was because of a lot of personal experiences. My father went blind when I was in senior high school. He was on the waiting list for 6 months and had one eye done initially, then [waited] another 6 months to have the second eye done. We didn’t have a resident Ghanaian ophthalmologist in our area, Agogo, at that time and the hospital had to recruit eye doctors from Germany who only came once every 6 months. I

also saw a lot of blind people begging by the roadside; they didn’t know that they could be helped and I thought I could be of help. We have many eye diseases that can cause blindness, like glaucoma, cataracts, trachoma, retinal diseases, refractive errors, etc. But cataracts are one of those where patients see real change when you remove them. You remove the cataract and people see a different world. One might think they had been reborn if you hear their stories. I had a woman who came and said, “Please if you can help me, help me. I can’t even see what I eat.” Then the next day she felt that she was a new person. It is a life changing procedure.

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How do you think ophthalmic care is perceived in Ghana, especially when diseases like malaria seem to dominate global attention? We have a huge challenge. With the mismanagement of limited resources and with the way we manage our resources, it is not adequate for developing eye care. Global initiatives like the Millennium Development Goals [international goals established by the United Nations to alleviate world poverty] are concentrated more on the so-called “killer diseases.” There’s tuberculosis, typhoid, diabetes, HIV. These are globally sensitive issues that concern the death of patients. We have diseases like malaria that are killing children. Eye diseases rarely cause death so we are sidelined, and the few resources we have are given to the killer diseases. But the need for eye care is great. That is why groups like Unite for Sight, Operation Eyesight Universal, the Swiss Red Cross, CBM, etc. support groups like us in developing countries. These NGOs see it as something that can help our countries to a certain degree, reduce poverty levels, and improve the quality of health. Because if I’m a breadwinner but I go blind, the whole family suffers. So if a blind person is able to regain his eyesight, he is able to help his family and the country as a whole. What’s your relationship with Unite for Sight?

How many ophthalmologists are there in Ghana? I know of about 76. The disparity is so great; more than half of the 76 ophthalmologists are based in Accra. And then 50% of the other half are affiliated with Kumasi [the second largest city in Ghana]. There are also areas without practicing ophthalmologists [as those ophthalmologists have taken on managerial positions]. One in the Eastern Region, one in the Upper West, one in the Upper East. Here right now, including myself, there are two ophthalmologists in the Northern Region. I run the outreach now in the Northern Region.

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Friends Eye Centre is a partner for Unite for Sight, and being the doctor in charge of Friends Eye Centre, I am a proud partner of this noble world-renowned organization. I am a member of the medical advisory board of Unite for Sight. Unite for Sight respects the views of its partners and there are proper checks and balances put in place to make sure that we are all on the same page in whatever we do together. Unite for Sight sponsors surgeries in the Northern Region and all other places we find people with treatable blinding diseases. The unique thing I find with Unite for Sight is that 100% of the money they fundraise goes directly into surgery, so there are no overhead costs, and that means more people benefit directly. Where/in what regions of Ghana do you work? Why? My focus area is in the Northern Region. Unite for Sight supports us anywhere the need for eye care is, whether it is in the Ashanti Region where my family lives, or in the Upper West where I originally come from, and now I’m trying to give back to society. Unite for Sight is very supportive in all aspects.

The North has always been considered the poorest place in Ghana. Diseases and poverty are more rampant here. All the natural resources and good pieces of land for agriculture are in the South. The South has been where development started. The South has always been higher than the North in terms of socioeconomic developments. The poor vegetation, poor irrigation system, arid environment, and poor education facilities in the North make things even worse. We were lucky only when the missionaries started building schools and hospitals in deprived areas in the North and trying to make them free. We are more than 50-100 years behind compared to the South. It has taken a long time to catch up in terms of socioeconomics, infrastructure, etc. The social amenities available in the South are not readily available in the North, and since health workers also want the best for themselves and their families, most of them will always refuse postings to the North. I went to the District Director in charge of health, and she was telling me that in the year 2015 the Northern Region had the worst indicators in terms of disease prevalence, maternal deaths, and infant mortality. We are last in all the indicators, which is something to worry about. But it is also a leadership issue in terms of the healthcare hierarchy. If we have leaders who want to engage everybody and recognize that everyone is important and seek their advice, they will motivate health workers at all levels and I think they will put in their best at their various special areas .

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If I’m a breadwinner but I go blind, the whole family suffers.

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What kind of people do you target?

We target all socioeconomic classes: those that can afford to pay for services at the clinic and those who genuinely cannot. But the majority are the poor, who we target with outreach. When you walk into the clinic, we want you to see that we need money to sustain medical facilities. When we go to outreach screen them and give them hope when they don’t have money, we are obliged to take care of them for free.

If we say “for free,” it’s free for the patient, but in the actual fact, somebody is paying for them. In our case, Unite for Sight pays for all our outreach surgeries without any hesitation. But what gives me the biggest job satisfaction is when a very vulnerable person who has lost hope in life and does not have hope, through us and Unite for Sight, is able to see again. You can’t help it. When you see their facial expressions, it makes you want to do more, and I highly appreciate Unite for Sight in that they support me to do that. Without their help, I don’t think I’d be able to do that. How are you able to reach those in need of ophthalmic care? In ophthalmology, we have two aspects of medicine: clinical and public health. We do both curative and preventive health services. We go to screen and then we give medication and perform surgeries to cure people from blinding cataracts and other diseases. We also do preventive care by educating and advocating for projects and programs that will prevent people from going blind needlessly, especially when it comes to trachoma control. My time is spent between the clinics and outreach services.

How much do surgeries cost? How much do you charge for surgery? Cataract surgery in my private practice costs 450 [Ghana Cedis], equivalent to about US$115, for people who can pay and walk into the clinic. However, when we go out on outreach to remote villages, all surgeries are sponsored by Unite for Sight. Unite for Sight-sponsored surgeries cost US$50 (200 Ghana Cedis). At the end of the day, we also want people to be responsible for their health. It is very important to let patients contribute a token towards their surgery so that gradually they are sensitized and prepared to take full responsibility for their health care costs when NGOs one day pull out of the program. That makes the patient take the surgery seriously. That’s why we give one bottle of eye drops after surgery free of charge to the patient (paid for by Unite for Sight), and subsequent bottles are paid for by the patient. This encourages him/her to understand the value so he/she won’t misuse the eye drops. How does traditional medicine play a role in eye care? Does it conflict with the ophthalmic care that you provide?

You’d be surprised to know that there are locations where traditional medicine is given official accreditation, and there is even an office for it in the headquarters of the Ghana Health Services. Some institutions and universities are still training people in traditional medicine to give treatment. It is no surprise that there are fake practitioners in medicine conniving to “treat” eye diseases and going to remote villages and cities convincing them that they have certain methods of treating eye diseases, cataracts for example, that do not involve surgery, and the people believe them. When we talk about surgery to an ordinary person, there are misconceptions and traditional beliefs that if a sharp object touches the eye, it will definitely go blind. Some also think that having surgery means that the eye is removed from the orbital cavity, the procedure is done, and then the eye is put back into the orbital cavity. People get scared of that and therefore are attracted to traditional medical practitioners who “couch” their eyes. Couching is one of the oldest methods of treating cataracts, dating back to the Roman Empire. It is a procedure where sharp pointed needles, not sterilized, are used to pierce through the limbus of the eye [the border between the cornea and the Kai DeBus

Nurses and Red Cross volunteers observe Dr. Wanye operating on a patient.

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white of the eye], manipulated to break the zonules [fibrous strands connected to the lens of the eye], and then used to push the lens to drop into the vitreous[clear, gel-like substance between the lens and retina].

Kai DeBus

How does it feel when you’re exposed to new equipment and techniques that are commonly practiced in developed countries, but you’re unable to utilize them, given the limitations of working in rural parts of Ghana? At times it makes me feel like a second- or third-class ophthalmologist when I am in the US and see all the latest sophisticated and expensive equipment for eye surgeries. But I feel good that even with limited resources, I can help many people see back at home in Ghana. Take the intraocular lens for example. In the US, you can measure the exact lens power with an “IOL Master” and even sometimes predict post-operative visual acuity. But if you want to get the best software and equipment, it can cost over $60,000. Even if we could afford to buy it, we can’t recoup the costs. But there are manual techniques that are less expensive, more cost-effective, and give good results too. That is why we do things our own way to help us in sustaining our work.

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What gives me the biggest job satisfaction is when a very vulnerable person who has lost hope in life and does not have hope, through us and Unite for Sight, is able to see again.

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Do you feel that brain drain is a major issue in Ghana, especially in healthcare?

People who train here in Ghana with taxpayers’ money get the opportunity and then they leave for greener pastures. While that’s their choice, we aren’t doing a good job of keeping health professionals in the country. Those who are work-

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Two plastic green cups are bandaged on the patient’s eyes following her surgery. Bandages are usually placed for at least a day in order for the eyes to heal.

ing hard to keep people alive aren’t being paid well and they aren’t being motivated. The high practice of corruption across the public sector also demotivates any professional from working hard for the betterment of the country. It is therefore not uncommon for health professionals to leave the country to work for foreign money which, when converted to the Ghanaian Cedi, is several fold more than what they would have received in Ghana. Many people believe that if you can make it to the West, you’ll live a prosperous life. While that is true, a lot of Ghanaian professionals get stranded in the West when they find out they cannot work or practice medicine without passing a certification exam, and most of them end up doing menial jobs in foreign lands. How do you see ophthalmic care in Ghana evolving in the next 10-15 years? I think we have a great future, but the biggest challenge is that ophthalmic care is not a priority to our healthcare system. I think we ophthalmologists should blame ourselves. In the US, ophthalmology is far, far [more] developed. They were able to lobby and calculate how much the nation loses when a patient becomes blind. We don’t do it here. Even though Ghana is the country with the most glaucoma patients [in the world] in terms of prevalence, we don’t make the case. Visually impaired and blind people constitute a huge economic cost to the country. There’s no commitment from the government, which makes the future

bleak. But people and NGOs are trying to help us, and that is exactly what Unite for Sight is doing. They mobilize and coordinate resources for a sustainable program. We believe that with intense advocacy and a clear focus on what we want to achieve for ophthalmology services, we will push the agenda forward and force the government of Ghana to contribute to providing comprehensive eye care services in Ghana in terms of providing modern equipment, developing human resources, and providing infrastructure. What kind of steps do you believe should be taken in order to provide better ophthalmic care/awareness in Ghana? We say that education is number one. We as eye care professionals should make people know the importance of their eyes and help them be ready to take responsibility for their own eye health. To do this education campaign properly, we should make sure the TV stations and radio station have slots for free healthcare talks instead of advertisements for alcohol. We need to develop simple local educational materials that can be easily used to explain the patient’s eye condition. We have a glaucoma association [the Glaucoma Association of Ghana] that should get free slots for TV discussions on glaucoma and other eye diseases that are most prevalent in our country. But how many people have TV sets, especially in the remote communities, to watch

Kai DeBus

Patients are asked to cover their eyes before surgery. This helps dilate the pupil, which allows operations like cataract surgery to be conducted more efficiently.

and listen to that? The important thing is getting adequate resources to embark on extensive educational, preventive and curative ophthalmic outreach campaigns, just as we are doing, and replicate that in all regions of Ghana. In 2010, we had a World Glaucoma Summit in Accra here in Ghana where we invited the [Ghanaian] politicians. What they heard and learned shocked them, and they promised to help the Ghana Health Service acquire a slit lamp, a visual field analyzer, and an operating microscope for each Regional Hospital. After a long push, the equipment was eventually procured for all the ten Regional Hospitals. There are a lot of barriers to uptake for eye care services and I think we as ophthalmic professionals have to work hard, do a good job with good surgical outcomes, and break all these barriers to make people have trust in the work we do. Do you have any advice for those who wish to pursue medicine or public health in a developing country?

There are always differences in healthcare systems in individual countries, so I think it’s good to get an idea of how the healthcare system works in any country where anyone is planning to pursue medicine or public health work. I think it’s also important to listen to the needs of the people in that country who are the direct beneficiaries of your services. Don’t think you can go and impose things just because you have better experience or more money. While practicing there, we need to understand the behavior of the people we serve, help them identify their health problems, and facilitate the process of them finding solutions to their own problems. These can be achieved through extensive engagement with the communities, education, and advocacy. If you have an idea, let them discuss it and allow them to come up with a solution. We also have to bear in mind that people in the US and other Western countries have a greater sense of responsibility and are more conscientious of the re-

spect that they’ll get. They want to do the right thing because if they don’t, they’ll be questioned and be held accountable. In most developing countries it is something different and we have to live by example, and I think that will draw more people toward us and will open avenues for us to effect change in the communities we serve.

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Kai DeBus is a junior in Saybrook College majoring in Ecology & Evolutionary Biology. Contact him at kai.debus@yale.edu.

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GLOBAL HEALTH TODAY

Colonialism, Civil War, and Ebola: Historical Perspectives On Contemporary Healthcare in Sierra Leone

By Elijah Rami

uring the mid-twentieth century, the British Empire rapidly succumbed to a striking decline. After the Second World War, its colonies in Africa and the Caribbean in particular witnessed a wave of nationalist movements that began to call for self-determination and independence from bureaucratic colonial administrations. Sierra Leone gained independence from the United Kingdom in 1961 after over a century and a half of British rule. After its one hundred and seventy-four years of rule, the British left Sierra Leone with a system of healthcare that was both under-resourced and inefficient after independence. This article will take a historical approach in order to understand the present state of Sierra Leone’s healthcare system, specifically why it proved ill-equipped to handle the horrors of the Ebola epidemic and the status of survivors of the virus in the present day. In its early years as a new nation, Sierra Leone suffered from the dictatorial rule of several of its initial prime ministers and presidents. Corruption on the part of politicians further diminished the economic standing of the country and continues to do so to this day. Under the rule of President Joseph Momoh in the 1970s, Sierra Leone reached a point where it could not import

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oil and gasoline, leaving the country without electricity for months at a time.1 Events in both the colonial and national history of Sierra Leone can readily and easily inform the current health of its people and the state of its healthcare system today in the twenty-first century. This article will examine the legacy of both the British colonial healthcare system and the legacy of the Sierra Leone Civil War of 1991-2002. Diseases such as yellow fever and malaria shaped life and policy in colonial Sierra Leone during the twentieth century. During this time period, the colony grappled with epidemics of fever and malaria during the period between the turn of the century and World War One. Colonial segregation policies in Sierra Leone, enacted as a result of deadly yellow fever and malaria epidemics throughout the eighteenth and nineteenth centuries, proved largely unsuccessful as they were based on scientifically inaccurate information and ultimately disenfranchised Africans even further. Africans were forced to live separately from white colonists, who were afforded special compounds by the colonial government. They were only allowed in the compounds for specific duties such as cooking and other domestic work during specified hours, never during the night.²

During the colonial period, little to no attention was given to the colony’s African population. Colonial administrators such as the prominent health examiner Rubert William Boyce viewed Africans as both harbingers of disease and literal diseases in themselves.3 Mismanagement and underfunding severely undermined education and eradication efforts and the calls of medical experts went largely unheeded. Africans continued to suffer from diseases such as yellow fever and malaria under colonial rule. The legacy of British colonialism and colonial health policy in Sierra Leone continued to leave a powerful legacy even after the colony gained independence and became a republic.

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During the colonial period, little to no attention was given to the colony’s African population.

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Today, after over fifty years of independence, Sierra Leone still faces serious issues with regard to the health and well-being of its population. The average life expectancy

for citizens was estimated to be about 57.8 years of age by the Central Intelligence Agency as of 2015.4 Over seventy percent of the population lives below the international poverty line.⁴ Diseases such as malaria and yellow fever have been endemic in the country for centuries. The country also suffers from intermittent outbreaks of cholera and meningitis. Much of the Sierra Leonean economy relies heavily on subsistence agriculture. Most healthcare infrastructure is designed for primary health care (PHC) and the country lacks major centers for surgery and emergency medicine. The country houses only three hospitals capable of performing major surgery and laboratory testing, which are scattered across three large cities. Each of Sierra Leone’s thirteen districts has a health management team comprised of about one hundred technical staff, including doctors, nurses and other medical providers. The team plans and monitors healthcare provision, trains personnel, and supplies equipment and drugs.5 Only about one hundred and sixty-eight doctors were present in the country of over six million people as of 2010—about one for every twelve thousand people.6 The country currently has a free system of maternal healthcare that began in 2010, through which pregnant and breastfeeding women are treated for no charge, along with children DFID

Dr. Asamte Fidel at work in the doctor’s office at Connaught Hospital in Freetown, one of Sierra Leone’s largest medical facilities.

under five. The initiative was created in order to reduce the high rates of maternal and infant mortality. However, the country lacks the infrastructure to properly implement the program. In addition, a majority of Sierra Leonean women do not know that they have a legal right to free prenatal care.7 As a result, poorly paid healthcare workers ignore the laws and take advantage of the population’s lack of knowledge by charging incredibly high fees that only few people can afford.7

Flickr/Global Panorama

Members of an Ebola awareness group in Sierra Leone

At the height of the war between 1991 and 2002, many hospitals were ransacked and used as hideouts and strongholds for rebel groups during the conflict. Hospitals that were not used as rebel hideouts were burned completely to the ground.⁸ The war completely devastated Sierra Leone’s economic and healthcare infrastructure. Over twenty thousand individuals died in the conflict. Rebel groups drew most of their recruits from Liberian refugees who had been staying in Sierra Leone as a result of conflict in their home country and needed food and medical care. Once this tactic failed, rebel groups recruited thousands of child soldiers to join their ranks. Many villages and towns were completely devastated. After the end of the conflict, Sierra Leone had to rebuild much of its infrastructure from the ground up. The country’s main teaching hospital in Freetown was able to stay open during the war, but it suffered shortages of medicines and other essential supplies and equipment, as well as a mass exodus of trained physicians and surgeons seeking to escape the conflict.⁸ As the war ensued, many people fled the countryside and moved into cities for safety and security. This mass migration into Sierra Leone’s largest cities exacerbated the dire health and sanitation situation in these areas.⁹ While healthcare services were limited at the time, healthcare centers in areas controlled by the government still managed to provide some services, albeit with fewer workers and supplies. However, provision of healthcare in areas controlled by rebel groups proved much more difficult. Agreements were eventually made between the government and rebel fighters to provide

limited services such as child immunization in areas under non-governmental control.⁹ Besides the loss of human lives and the destruction of healthcare infrastructure, perhaps the greatest health crisis that emerged after the end of the civil war was a surge of mental health issues in response to the conflict. Many Sierra Leoneans continue to suffer from immense trauma after experiencing the horrors of the war. Both rebel groups and government soldiers routinely fired guns in towns and villages. Civilians witnessed widespread killings and the burning of homes and other buildings. People lived in constant fear of attack or death and many had to flee their homes due to the conflict. Today, a decade and a half later, the number of individuals suffering from mental trauma in Sierra Leone remains unknown, but estimates put it in the hundreds of thousands.10 Statistics taken in 2002 by the Sierra Leonean Ministry of Health and Sanitation placed the rate of severe mental illness at over four times the global average.10 To make matters worse, mental health care in the country is almost nonexistent. Many child soldiers witnessed severe atrocities and former child soldiers suffer from severe mental illness and substance abuse as a result of their trauma.11 The understanding of issues around mental healthcare in Sierra Leone prove vital to addressing contemporary healthcare issues facing the country, as psychological trauma shapes much of the country’s modern history and healthcare issues. The 2014 outbreak of Ebola virus in the country only further exacerbated existing

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issues present in Sierra Leone’s healthcare system. At the time of the outbreak, it was believed that the virus was not endemic to Sierra Leone, or the West Africa region as a whole.12 However, testing of samples of Lassa fever (an arenavirus endemic to West Africa) from clinical trials revealed that Ebola had been present in Sierra Leone since at least 2006, nearly a decade before the start of the epidemic.13 The Ebola virus affected all aspects of life in Sierra Leone at the time of the epidemic’s height, as immense pressure was placed on a healthcare system that had not been prepared to cope with a healthcare emergency on such a large scale. Many hospitals quickly ran out of beds and many healthcare workers, both Sierra Leoneans and foreign doctors and nurses who came to the country to aid in the relief efforts, either succumbed to the virus themselves or had to be medically evacuated to the United States or Europe for treatment.

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party. The government of President Ernest Bai Koroma delayed the clearing of the container in order to prevent the political opposition from taking credit for the donated supplies.14 Across West Africa, over eleven thousand people died from the virus, with nearly four thousand of these deaths occurring in Sierra Leone alone.15 The World Health Organization declared the country Ebola-free in March 2016. The epidemic had subsided in the months leading up to the WHO’s announcement, but many flare-up cases had occurred. With over four thousand lives lost to the virus, the country not only faces infrastructural and political challenges, but also socio-cultural challenges surrounding the well-being of both survivors of the epidemic and ordinary Sierra Leoneans. During the epidemic, many Ebola victims were placed into forced quarantine, separating them

The current state of Sierra Leone’s healthcare infrastructure cannot be blamed entirely on a corrupt and inefficient government.

The country’s political infrastructure also proved intransigent in its actions at times, as there were instances of politicians taking advantage of the epidemic to further their own means. One well-documented case uncovered a scandal surrounding a shipping container from the United States that had been sitting unopened in Freetown for over two months. The container had been full of $140,000 worth of medical equipment (including gloves, protective gowns, stretchers, and mattresses), whose shipment had been organized by a senior official in the country’s main opposition

Flickr/Global Panorama

Medical workers transport a recently deceased Ebola victim. One of the most dangerous characteristics of the virus is that it can be transmitted through dead bodies, making proper care and removal of the dead a priority during the West African epidemic.

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from the rest of society for days, weeks, or months at a time. At the end of the epidemic, many Ebola survivors returned home from treatment centers only to be chased out of their homes and shunned from their families and communities. Market sellers found difficulty selling their wares as people would not touch them, and many survivors found themselves abandoned by their spouses.16

As serious, long-term outbreaks of Ebola are only a very recent phenomenon (outbreaks before the 2013-2016 West African epidemic were small and isolated), scientific and medical understanding of the disease is still catching up to match the scale in which recent epidemics have occurred. As of now, there exists almost zero public health data on the outcomes and statuses of survivors of Ebola in West Africa, with the 17,000 survivors of the epidemic making up the largest data source on the virus in history.17 It has been found that Ebola has a devastating impact on the brain, with many people hallucinating or falling into comas.17 This impact of the virus on the brain must be taken into consideration when addressing issues around recovery, as Sierra Leone already faces an extreme dearth of mental health care resources, and a significant portion of its population is still left traumatized from the decade of civil war and the recent epidemic. With so little data on survivors of

DFID

British Army Sergeant Sulaiman Kamara meets Ebola survivors in Magazine Wharf, Freetown.

the epidemic, there are a host of potential issues linked to the virus post-infection that have yet to be discovered. While a century and a half of colonial neglect and the atrocities of post-independence civil war damaged Sierra Leone’s healthcare infrastructure, there remains hope for the country. The Sierra Leonean government currently partners with various non-governmental organizations such as the Red Cross and a few smaller charities in delivering healthcare to its populace. The primary treatment centers have been restored to their previous states before the war, and continue to receive support in the form of foreign medical instructors and practitioners.17 In neighboring Liberia, the US National Institutes of Health has launched the PREVAIL program, the largest long-term clinical study of Ebola survivors, with smaller studies in Sierra Leone and Guinea. The current state of Sierra Leone’s healthcare infrastructure cannot be blamed entirely on a corrupt and inefficient government. The legacies of colonialism still impact the country today, as the British exploited much of its natural wealth in diamonds and other natural minerals for the sole purpose of bringing them back to the colonial metropole for a profit, while completely ignoring the health and well-being of its native black populations. Today, Sierra Leone must grapple with this colonial legacy, as well as the legacies and traumas of civil war and the deadliest biomedical outbreak it has ever witnessed, as it continues to grow and develop in the twenty-first century. www Elijah Rami is a sophomore in Ezra Stiles College. Elijah is a history major from New York. He can be contacted at elijah.rami@yale.edu

GLOBAL HEALTH TODAY

DETONATION DEBRIS: The Global Health Implications of a Nuclear War By Sarah Spaulding

Wikimedia

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n recent years, the topic of nuclear weapons has been a hotbed of political controversy across the globe. Many argue that the widespread use of nuclear weapons is a more plausible reality today than ever before, but the threat of nuclear war has existed ever since the culmination of the US Manhattan Project with the first nuclear bomb detonation in Alamogordo, New Mexico on July 16, 1945.1 Today, at least nine nations currently possess a combined estimate of 15,500 nuclear warheads.2 Over 90% of these belong to Russia and the United States, each of which have over 7,000 nuclear weapons.2 Although initial major nuclear reports from the 1980s focused on the threat of nuclear war between the US and the former Soviet Union3, today China, India, and Pakistan are all pursuing new missile technology, sea-based nuclear deliveries, and other nuclear advances. Additionally, North Korea is continuing to violate previous denuclearization pledges by advancing its nuclear weapon program.2 Never before has the world seen such widespread nuclear capabilities, and never before has the potential extent of nuclear war been so great.

One of the most harmful effects of a nuclear war would come in the form of much higher levels of cancer incidence in the human population. A 2008 study suggests a “modest” estimate of 5 teragrams (Tg) of elemental carbon (soot) emissions from a regional nuclear conflict could elevate stratospheric temperatures 30 degrees Celsius, reducing 20% of the global ozone layer, with losses as large as 70% at northern high latitudes for as long as five years.4 This would dramatically increase both the duration and intensity of UV radiation reaching the Earth’s surface, in turn raising cancer rates. Additionally, although the mechanisms are not well known, evidence suggests a nuclear conflict could affect the exposure pathways of chemicals and toxins produced by nuclear weapons, further complicating the risk of cancer in the human population.5

temperatures around those of the last Ice Age. Furthermore, global rainfall could be reduced by more than a quarter of its annual levels.4 This would drastically shift the growing season of crops, and in turn, the available food supply. For example, a nuclear war simulation in several provinces of China yielded an almost 100% reduction in rice crops in the northern areas, and reductions ranging from 10-42% in crop yield of southern areas.6 Climate models for a 5 Tg elemental carbon emission following a nuclear conflict correspond to a reduction in growing season rivaling the shortest average growing season length observed in “Midwestern corn-growing states.”4 This leads to food shortages and the proliferation of food contaminants due to changing ecosystems and the proliferation and termination of different species in response to changing precipitation and

This imminent nuclear threat poses major challenges for global health. Aside from the immediate resulting harm - namely the massive casualties in the immediate vicinity of a nuclear explosion due to blast, heat, and fallout - a major nuclear conflict (typically discussed on the scale of 100 Hiroshima-sized bombs) would upend the entire planet, leaving global health in a state of abysmal ruin. Researchers forecast spikes in cancer and genetic defects, mass starvation, and the global spread of epidemics due to a variety of environmental changes resulting from the nuclear explosion. Immediately following a nuclear explosion, the resulting blast would kill almost everyone - even those in nuclear shelters - within a close range (up to two kilometers).3 Outside of a 10 kilometer range, the probability of death drops off, but people in the area would still be deeply affected by the long-lasting impacts of a nuclear detonation.3 By the second half of the Cold War, at the height of the global nuclear weapon count, researchers estimated that up to 500 million people could be killed immediately from the explosion of weapons in a nuclear war, a figure that has since been deemed an underestimate by modern models and is highly dependent on the population density of the directly bombed areas.3,4 Beyond these immediate impacts, which would largely occur within 24 hours of a nuclear explosion, radiation and changes in the environment would create long-lasting mass health problems that could affect the human population for centuries.

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John Urban In the Quảng Ngãi province of southern Vietnam, a baby is born with a cleft palate, a common birth defect. An increase in radiation exposure in the aftermath of a nuclear war would increase the frequency of birth defects.

Several of the most widespread health effects resulting from a nuclear war are all borne out of the same issue: destruction and lack of food and agriculture. The resulting major health issues are catastrophic, including foodborne diseases and malnutrition, which in turn give way to developmental and genetic defects. Researchers estimate that 5 Tg of elemental carbon emission in the wake of a regional nuclear conflict would be enough to cause the lowest temperatures seen on Earth in 1000 years.4 In contrast, emissions totaling 75 Tg, less than half of the predicted emissions in a hypothetical nuclear war between current global nuclear powers based on nuclear arsenals regulated by the Treaty of Strategic Offensive Reductions, would be sufficient to reach

temperatures. In addition, a decline in food supply and adequate nutrition would affect human development during fetal and early youth stages of development. Combined with higher rates of exposure to toxic contaminants, these factors create the perfect environment to give rise to higher incidences of birth defects, due to improper developmental nourishment. These massive, long-standing changes caused by a nuclear clash would also affect other aspects of global health. The increase in air pollution due to the release of particulates and aerosolized toxins, as well as the exposure to seasonal air elements such as pollen as a result of changing growing seasons, could contribute to high incidences of asthma

David Iliff Looking down from the Hollywood Hills, air pollution clouds downtown Los Angeles. The release of particulates and aerosols during a nuclear war would drastically increase air polution, which could contribute to higher incidences of respiratory diseases.

and related respiratory diseases. Increased temperatures in certain regions and changing disease vectors, as a result of climate and ecosystem shifts, would likely increase cardiovascular disease and stroke rates. Extreme weather events, such as monsoons, hurricanes, droughts, and wildfires, due to changing ecosystems and water supply, could increase mortality rates among those in the affected areas. Rates of waterborne and vector-borne diseases, such as cholera, malaria, and giardia, could skyrocket in response to shifts in precipitation patterns, coastal environments, and relocation of large populations. Lastly, neurological diseases and mental health disorder rates would also likely increase, as a result of higher stress placed on individuals from factors such as geographic displacement, death of relatives, extreme stress, exposure to biotoxins, and malnutrition. Although total global nuclear weaponry has decreased three-fold since its peak towards the end of the Cold War, a nuclear war still remains a massive threat to the stability of human health around the world.7 Much of this stems from the refusal of every nation currently in possession of nuclear weapons to disclose the official contents of their respective arsenals. Thus, much of what we know about current nuclear warhead counts is rooted in various international treaties and data concerning nuclear delivery systems in each nation and in regular releases of the Bulletin of the Atomic Scientists.8 Other nuclear estimates are based on approximations of fissionable material in nuclear weapon states, such as plutonium produced in nuclear reactors, and attempts to match up the data with plausible weapon assembly counts. This has been done by the Institute for Science and International Security for nations including India, Israel, North Korea, and Pakistan, but leave much uncertainty and lack of confirmation associated with the estimates.4 This international silence on nu-

clear weaponry is one of the major roadblocks impeding scientists’ ability to understand and tackle the issues of global health in the wake of a nuclear war. Without more exact and specific data on the sheer size and potentials of the weapons in each nuclear nation, we are unable to wholly predict the global health effects of a major nuclear conflict. What is clear, however, is the imperative need for further reduction of nuclear inventories at a much faster speed. As early as the 1970s, the nuclear programs of the US and Russia were capable of overkill, a term coined by Nobel Peace Prize winner Philip Noel-Baker, referring to the ability to “exterminate a population more than once,” and something Noel-Baker claimed the world might be capable of doing “ten times over.”3

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Armed with the current bed of nuclear information available, we must identify major potential global health issues and work to provide solutions as best we can.

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Ultimately, our lack of information about current nuclear stockpiles impedes the ability to adequately evaluate, assess, and attack the global health crisis that would undoubtedly occur following the use of multiple nuclear weapons. Armed with the current bed of nuclear information available, we must identify major potential global health issues and work to provide solutions as best we can. For cancer, this involves an active effort to understand carcinogen exposure pathways, investigate effects of ozone layer mitigation, investigate adaptation measures on rates of cancer incidence, and formulate oncologic therapies and treatments to optimize the best solution. For

foodborne diseases and malnutrition, it is essential that we work towards a more informed stance on how changes in agriculture and fisheries impact food supply and nutrition, a stricter supervision of disease-related agents, and an understanding of intricate food and organism relationships to further our ability to brace healthcare sectors for an onset of new diseases. With regards to developmental and genetic defects, the crucial steps to improving this issue lie in a greater understanding of factors affecting both the supply and quality of food, as well as identification and mapping of pesticide use, toxic contamination, and expanding disease ranges. In a study completed in the final years of the Cold War, one researcher declared, “What can be said with assurance...is that the Earth’s human population has a much greater vulnerability to the indirect effects of nuclear war [including damage to the world’s agricultural, transportation, energy, medical, political, and social infrastructure], especially mediated through impacts on food productivity and food availability, than to the direct effects of nuclear war itself,” and that ultimately “the indirect effects could result in the loss of one to several billions of humans.”9 Aside from the crucial reduction and eventual elimination of nuclear warheads from the face of the Earth, this preparation and research, which may seem futile in the face of immediate mass casualties following detonations of weapons in the event of nuclear warfare, will be the key to success against the threat of nuclear war.

www Sarah Spaulding is a junior in Jonathan Edwards College majoring in Environmental Engineering and Ecology and Evolutionary Biology. She can be contacted at sarah.spaulding@yale.edu

YALE GLOBAL HEALTH REVIEW

Jessica Tantivit, Yale University, TD ‘18

FIELD WORK

Inside the Doctor-Patient Relationship of China F

By Sophia Yin

or Chinese doctors, patient satisfaction can be—quite literally—a matter of life or death. Official data from China’s Ministry of Health reported “9,831 ‘grave incidents’ of medical disputes in 2006, with 5,519 medical staff injured and 200 million yuan (over 29 million dollars) in property damage.1 Such violent incidents are widespread across the country. In September of 2011, a Beijing calligrapher became so dissatisfied with his throat cancer treatment that he stabbed his doctor seventeen times.2 In Wenling City in 2013, a patient attacked three doctors, killing one of them.3 In February 2014, patients “paralyzed a nurse in Nanjing, cut the throat of a doctor in Hebei, and beat a Heilongjiang doctor to death with a lead pipe.”4 Just last year in Guangdong Province, a knife-wielding patient chased a doctor down the halls of the hospital, slashing her arms and legs.5 Such reports of dissatisfied patients attacking their doctors are becoming increasingly common in China. The Chinese Hospital Management Association found that “violence against medical personnel rose an average of twenty-three per cent each year between 2002 and 2012. By then, Chinese hospitals were reporting an average of twenty-seven attacks a year, per hospital.”4 Violence toward doctors is not rare or limited to China––such acts are often symptomatic of a larger societal frustration toward the healthcare system. But why are assaults on doctors so prevalent in China specifically? To answer this question, many legal experts point to the lack of a unified medical negligence legal system. The United States, in contrast to China, has an established and commonly used sys-

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tem of laws dealing with medical malpractice.6 A patient in America must show that the physician “acted negligently in rendering care, and that such negligence resulted in injury” by proving “(1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages.”6 Damages are usually awarded in the form of money and typically take into account actual economic loss as well as pain and suffering.6 Though the US medical malpractice system is by no means perfect, it generally provides an adequate avenue for expressing grievances. Injured patients are less likely to feel the need to take matters into their own hands outside of the law. In China, on the other hand, medical negligence laws are less uniform. Since the State Council announced the Regulations on Handling Medical Accidents in 1987, medical negligence laws been separately written and enforced by both the government and health administrative agencies, which often leading contradictions.7 The system tended to favor medical care providers by constraining “the scope of medical negligence liability to the narrowly defined medical accident (so that many adverse events are not actionable)” and limiting the damages considered recoverable.7 In 2002, a major reform created the Supreme People’s Court, China’s highest level court, “establishing a distinct judicial medical liability regime”, but it was not until the passing of the 2010 Tort Liability Law that the two regimes were bridged.7 The Supreme People’s Court has also recently introduced many pro-plaintiff judicial rules “to reduce the plaintiff’s costs of proving negligence (by shifting the burden of

proof to the defendant), to extend the scope of liability (to cover non-medical accident negligence), and to increase the damages recoverable.”7 As a result, the Supreme People’s Court reported that “courts nationwide heard nearly 17,000 medical malpractice claims in 2010, an increase of 7.6% over 2009.”7 Despite decades of legal reforms and strengthening of legal institutions, there has yet to be a large-scale reform of China’s medical-malpractice legal system. Some actually criticize the development of the legal system as a part of the problem. A report by Yu et al. written in 2015 cited “increased awareness of patient’s rights, and legal consciousness as well as poor quality of medical services” as “the most important reasons for the increasing acts of violence against the healthcare professionals.”8 The study explains that as patients became more aware of their rights, “patients and their relatives no longer remain silent regarding medical malpractice or medical negligence on the part of doctors or nurses.”8 Perhaps social factors are more at the root of patient anger than legal systems. In China, there is very little trust in the doctor-patient relationship. One reason for this is rising healthcare costs. In the 1980s, the government “reduced subsidies for hospitals and at the same time allowed them autonomy to earn income from sales of services and drugs.”9 With less money flowing in, hospitals responded by charging more for and possibly overprescribing tests and medications. Over this same period, the proportion of the population with insurance coverage also decreased, falling from 70% in 1981 to 20% in 1993.9 As of 2008, “households’… out-of-pocket payments… are more than 18 times what they were in 1990.”10 More than 35% of urban households and 43% of rural households said they had difficulty in affording health care” in 2006.10 To address these problems, the government recently began healthcare reforms to give social health insurance to more of the population, allowing “more than 95% of the 1.3 billion Chinese people [to have] a basic safety net.”11 However, this insurance coverage is incredibly basic, “leaving patients liable for about half of total healthcare spending, with the proportion rising further for serious or chronic diseases such as cancer and diabetes.”12 With the costs of hospital care being so high, many naturally expect correspondingly high quality care. These expectations are rarely met. Doctor-patient interactions are often extremely brief, limiting the ability to form a strong doctor-patient relationship. I observed this first-hand in China two years

ago, when I shadowed some Chinese doctors as a part of the Yale MedX trip. Walking into Xiangya First Hospital (located in Changsha, capital of Hunan Province) felt more like going into a shopping mall on Black Friday than entering a hospital. The escalators were packed. The lines for registration numbers or to pick up medicine stretched for miles. The waiting rooms looked like New York City train terminals. The lobby overflowed with people. Dr. Li, whom I was shadowing, explained that people were seen on a first-come, first-serve basis. Many of the people who we saw had arrived around 6 a.m. to stand in line for a registration number.

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Doctors in China must be extremely efficient – there really is no time to even have a conversation, much less form a relationship.

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Some of the hospital crowding can be explained by China’s high population density. Xiangya First Hospital was especially affected because it was a major hospital in a major city. People from surrounding rural areas congregate at such major hospitals in order to receive better care, even though transportation is often expensive. Doctors are rushed through each patient interaction in an effort to see as many of the sick as possible. Even with minimal doctor-patient interaction, many have to wait multiple hours before seeing a physician.

While in China, I also visited the office of a neurologist as he met with patients. By the time I made my mid-morning visit, he had already treated 40 patients. In the fifteen minutes that I was with him, he saw four more. Doctors in China must be extremely efficient, and therefore impersonal – they have no time to converse casually and form a relationship. The physician glances at scans, asks about symptoms, makes a diagnosis, prescribes treatment, and sends the patient on her way. Even before a patient’s meager time with the doctor is technically finished, the next patient in line often interrupts their appointment, knocking on the door loudly or even pushing into the room, trying to hurry the doctor. What we observed seems to be typical of what Chinese doctors face every day. As Dr. Zhong Nanshan, one of China’s most respect-

ed doctors, stated at a 2014 meeting of the National People’s Congress in Beijing, “The reality for patients is wait for three hours to see a doctor for three minutes.”13 Christopher Beam, a journalist for The New Yorker, interviewed a leading radiologist in Shanghai, who recounted that “the record number of patients seen in a day is three hundred and fourteen, which equates to ‘One doctor, 8 a.m. to 6 p.m., ten hours, two minutes per patient’.”4 A study done in the Shaanxi Province of China found that “the average visit to a doctor’s office lasts seven minutes, and physicians spend only one and a half minutes of that time talking to the patient.”4 In the United States and Sweden, the average visit is usually at least twice that.14 In seven minutes there is barely enough time to establish a diagnosis, much less a relationship. There are clear bases to patient frustration in China. And while systematic medical inefficiency does not excuse a patient’s violence, one can empathize with these victims of a harsh system. Christopher Beam recently wrote about the series of events that led Li Mengnan, a seventeen-year-old patient, to fatally stab Dr. Wang Hao and slash three others. When the news first broke of the killing, the media reviled Li. But as new details emerged about him, “the media’s portrait of the killer softened: Li Mengnan wasn’t a lunatic, nor did he have a history of violence. He was a man whom society had failed so completely that he was impelled to lash out.”4 Beam reported that, after a rough childhood, Li was working in Beijing at the age of fifteen when he began to have severe leg pain.4 He went to the hospital, but was unable to afford the tests necessary for a full diagnosis.4 He returned home to rural Mongolia, where he was unable to receive treatment since the local hospital, like most rural ones, did not have the specialists and equipment needed to make complex diagnoses.4 In September of 2010, Li and his grandfather took a ten-hour train ride to Harbin, the nearest major city, to visit a top-tier hospital.4 Like all major hospitals, the hospital was incredibly busy, and his doctor, very sadly, misdiagnosed him.4 Because Li was not getting better with the treatment the doctor prescribed, he and his grandfather returned to the hospital in April, where he received the correct diagnosis of ankylosing spondylitis, a “chronic inflammatory disease that can result in a complete fusion of the vertebrae.”4 The disease cannot be cured, but doctors proposed treating the symptoms with Remicade, an intravenous drug that

YALE GLOBAL HEALTH REVIEW

costs “thirty-nine thousand yuan (more than six thousand dollars) for the course of injections.”4 Though Li had some insurance as a migrant worker, he still needed to pay eighty thousand yuan out-of-pocket, which the family “scraped together…using Li’s welfare subsidies and his grandfather’s pension, and borrowing the rest from family and friends.”4 The Remicade injections relieved Li’s symptoms, but after a month, doctors told Li they would have to halt the injections because he had tuberculosis, likely because the drug had weakened his immune system.4 Li spent the next four months in a hospital in Hulunbuir being treated for his tuberculosis.4 Then, once again, Li and his grandfather made the ten-hour trek to Harbin, optimistic that Li could restart his Remicade injections.4 When the arrived at the hospital, “the doctors at the hospital had sent him across town to a clinic for an X-ray, only to tell him, when he came back, that he should have brought the clinic’s notes with him. When he returned with this paperwork, they told him that they couldn’t treat his spinal problem after all” because the tuberculosis had not completely left his system.4 Li was told that he would have to wait three more months for the Remicade treatment and would thus have to return home untreated.4 Even worse, “the doctor didn’t tell Li the bad news directly; instead, he made him stand outside his office while he talked to Li’s grandfather.”4 This moment, according to Li’s lawyer, was when “his client felt most insulted and led him to think, ‘Are the doctors tricking me?’.”4 As Li’s lawyer stated, “ ‘All he knows is he’s been there many times, and each time it’s ‘No, no, no.’”4 Li had to suffer through high costs, long travel and wait times, and years of waiting – first, for the right diagnosis and then, for the tuberculosis to be treated.

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While patients are by no means excused in their violence, they too are victims of the system.

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With little trust in the system or his doctors, Li’s anger turned deadly. He left the hospital and bought a three-inch fruit knife from a nearby store.4 Though “he later said that he’d been looking for the doctor who had refused to treat him…when he came out of the elevator he approached the first white coat he saw,” stabbing Dr. Wang Hao.4

VOLUME 4, NO.2

Jessica Tantivit

The lobby of Xiangya First Hospital in Changsha, China, was packed with people, waiting for registration numbers or to pick up medicine, and the waiting rooms looked like train terminals. Many of the people that we saw had arrived around 6 a.m. to wait in line.

At the trial, Li’s lawyer argued that, “the hospital had detected tuberculosis before giving Li the injections, inviting the suggestion that it hadn’t said anything because the medication is so lucrative.”4 Essentially, the lawyer argued that because the hospital exploited a sick patient for his money, disregarding his well-being and treating him as a cash funnel, Li’s sentence should be mitigated. But the judge was not to be swayed: Li is now serving a lifetime in prison. On the second anniversary of Wang’s death, Beam interviewed the parents of the murdered doctor. He asked Wang Dongqing [Wang Hao’s father] whom he blamed for his son’s death.4 Though very much still grieving his son’s death, Wang Dongqing replied, “I blame the health-care system… Li Mengnan was just a representative of this conflict. Incidents like this have happened many times. How could we just blame Li?”4 How can China fix such a broken system? Its issues are complex and tangled, without a simple or complete solution. Some experts have proposed a return to community care, a practice which has a lengthy history in China. In the twentieth century, China had great success with “barefoot doctors.” Though these were not highly technically trained doctors, they were able to provide basic health services, such as primary and preventive care as well as maternal and child health.15 Barefoot doctors focused on serving rural and underserved areas at the village level, allowing them to vastly improve the health of those they served as well as to forge personal re-

lationships with their patients.15 As a result of the barefoot doctors, the infant mortality rate in the country from 200 per 1,000 births to 34 deaths per 1,000 births between 1952 and 1982.15 The ability for these healthcare providers to form close relationships with those they served allowed for greater trust. The incidents of attacks against doctors are often a manifestation of the broad frustrations for the inadequacies of the healthcare system. High healthcare costs, poor relationships between doctors and patients, and the lack of well-established malpractice laws are all problems to tackle. Solutions that focus on establishing a wider network of reliable primary health care providers who can form close relationships with those they serve show great promise. Not only will health outcomes of those in rural areas likely improve, but much of the pressure on doctors in urban hospitals will be relieved. With fewer rural patients coming in for minor illnesses or waiting for minor illnesses to become major ones that necessitate going to a major hospital, urban doctors will hopefully have more time to form relationships with their patients, reducing the likelihood that a dissatisfied one returns for revenge. www

Sophia Yin is a junior in Berkeley College majoring in Psychology, Neuroscience Track. Contact her at sophia.yin@yale.edu.

INDIA:

ENVIRONMENTAL HEALTH

Delhi’s Air Pollution and its Effect on Children’s Health By Rebecca Slutsky

Wikimedia Commons

hich of our world’s cities has the worst air pollution? According to the World Health Organization, it’s Delhi, the capital of India.1 Although air pollution affects the entire population of this metropolis, Delhi’s children are the most defenseless against its toxic effects. Recent studies have confirmed serious deterioration of air quality in Delhi, as well as other major cities across India. Air pollutants such as sulfates, nitrates, and black carbon force their way into the developing lungs and cardiovascular systems of children, resulting in decreased quality of life and increased mortality rates.1 Air quality has deteriorated to such an extent that one of India’s top pollution researchers, Sarath Guttinkinda, has stated, “If you have the option to live elsewhere, you should not raise children in Delhi.”2 He has since moved his family out of Delhi to protect his two young children. On September 27, 2016, The World Health Organization (WHO), an agency of the United Nations that focuses on international public health, released a new air quality model revealing that 92% of the world’s population lives in places where air pollution levels are greater than WHO-recommended limits.3 The report indicated that over 3 million premature deaths around the world each year are associated with exposure to outdoor air pollution. India has the world’s

highest mortality rate from respiratory disease, with 159 deaths per 100,000 in 2012, about twice that of China’s. 4 Delhi’s air is more than two times as polluted as Beijing’s, which has the highest rate. 2 And while the smog in China’s major cities get most of the world’s attention, six of the ten most polluted cities in the world are in India. 5 In addition to Delhi, the other highly polluted Indian cities are Gwalior, Allahbad, Patna, Raipur, and Ludhiana.6 Air pollution in India is ten times the WHO’s recommended maximum, twelve times the standards employed in the United States, and over twice the level considered acceptable by the Indian government.7 Flavia Bustreo, WHO assistant director general, stated, “When dirty air blankets our cities the most vulnerable urban populations, -the youngest, oldest and poorest- are the most impacted.”1 Air pollution refers to the adulteration of the earth’s atmosphere with particles that compromise human health, quality of life or the natural functioning of the ecosystem. 8 Air quality is generally measured by looking at exposure to tiny particulates smaller than 2.5 microns, known as PM2.5s, which penetrate the lungs. The PM2.5 standard includes particles with a diameter of no more than 0.0002 inches or one-seventh the width of a human hair. 1 The recently released WHO urban database reports

that Delhi has exceeded the maximum PM2.5 limit by almost ten times.8 Only two other cities in the world, Ludhiana and Kanpur, exceed Delhi’s levels. Notably, these cities are also located in India. In fact, air pollution is now the fifth largest killer in India, according to a 2010 report of the Global Burden of Disease (GBD), which tracks illnesses and deaths worldwide.9 About 620,000 premature deaths occurred in India from diseases related to air pollution in 2010, a six-fold increase from 100,000 deaths in 2000.10 49% of these deaths were caused by heart disease, 25% by stroke, 17% by chronic obstructive pulmonary disease, 7% by lower respiratory infections, and 2% by trachea, bronchus and lung cancer.9 Scientific studies on the effects of air pollution on children in India conclude with certainty that for many, their health will be compromised for the rest of their lives. An extensive three-year study that was published in 2010 and was conducted by the Kolkata-based Chittaranjan National Cancer Institute (CNCI) in conjunction with WHO found that key indicators of respiratory health, lung function, blood pressure in children in Delhi between four and seventeen years of age were far worse than those of children elsewhere. The tests were conducted on a total of 11,628 school-age children from 36 schools throughout Delhi and 15 rural schools in West Bengal and Ut-

YALE GLOBAL HEALTH REVIEW

taranchal. 11 Specific findings from lung tests show that 43.5% of the Delhi school children suffered from “poor or restrictive lungs,” as compared to 22% of the kids in the rural schools.12 Alveolar macrophages (AM), lung cells that clean off microorganisms and dust particles, were 2-3 times more frequent in Delhi school children than in rural children. This high AM number indicated that the Delhi children had greater exposure to particulate pollution, as AM represents the first line of cellular defense against inhaled pollutants. 11 Additionally, about 15% of the children in Delhi reported frequent eye irritation (vs. 4% of rural children), 27.4% reported frequent headaches (vs. 12% rural), 11.2% experienced nausea (vs. 5% rural), 7.2% reported heart palpitations (vs. 3.3% rural) and 12.9% were fatigued (vs. 6.7% rural).13 The report concluded that about half of the 4.4 million children who reside in Delhi already have irreversible lung damage. 12 Delhi’s poorest children are the most vulnerable and bear the most burden of the city’s poor air quality. There is an inverse relationship between socioeconomic status and the pervasiveness of lung function deficits: the lower the socioeconomic status, the greater the percentage of children with reduced lung function. 11 According to WHO’s 2016 urban air quality database, 98% of cities in low-and middle-income countries with a

population greater than 100,000 do not meet WHO air quality standards. However, in high-income countries, this percentage is a much lower 56%.4

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The rapid deterioration in air quality in cities like Delhi is the result of a combination of exploding populations and the lack of stringent government regulations to control smog and soot from rapidly growing industry, transport, and construction.1 Anumita Choudhury of the Centre for Science and Environment, a Delhi thinktank, says part of the problem, “is a mobility crisis as use of private vehicles has soared while public transportation has suffered chronic under-investment.” 7 Between 1991 and 2011, Delhi’s population more than doubled to 22 million, and the number of cars increased five times to about 8 million, at a rate of half a million new cars per year.10 Another major contributor to air pollution in Delhi is the presence of the 70,000 trucks that drive directly through the city on long distance journeys. The government is aware of this issue but its

plan to build a bypass has been delayed year after year. 7 In the meantime, there is a very young poor population currently being exposed to this severe roadside pollution. Many children walk to school along busy roads, receiving extremely high doses of toxic chemicals and damaging particulates. The daily levels of toxic air in Delhi schools, which are often close to roads, are more than ten times worse than acceptable, according to the WHO. 7

When dirty air blankets our cities the most vulnerable urban populations - the youngest, oldest, and poorest are the most impacted.

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Dr. Sanjeev Bagai, a Delhi pediatrician, stated that the number of children he has treated who have been impacted by air pollution has more than doubled in the last ten years. He said children of all age groups are vulnerable and “even newborns have respiratory diseases, which were previously not seen so early in life.” 10 The WHO has found that children are most susceptible to the harmful effects of air pollution for a number of reasons. Children spend more time outdoors than adults, and are outdoors during the middle of the day when air pollution levels are higher. 11 Children’s bodies also demand significantly higher oxygen levels so their respiration rates

TrekEarth

Crowded streets and everyday traffic in the city of Delhi.

VOLUME 4, NO.2

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The rapid deterioration of air quality in cities like Delhi is the result of a combination of exploding populations and the lack of stringent government regulations.

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are higher and they inhale more air per unit of body weight than adults do. Additionally, because of children’s small stature, their breathing zone is closer to the ground where the most polluted air is. This means they are continually inhaling air loaded with the most particles.14 Further, the diameters of the alveoli in their airways are narrower, which makes

them more easily affected by inflammation caused by air pollution.11 Children’s lungs are still developing and their immune defense is immature so, as a result, they are more vulnerable to toxic pollutants. 15 The WHO concludes that exposure to toxic air during childhood reduces lung growth and the adult-maximum functional lung capacity, which can result in increased susceptibility to infection and pulmonary and vascular diseases, even past adolescence.14 The WHO also concludes that polluted air affects development of the nervous system in children, potentially reducing cognitive function. 15 Delhi has taken small steps to reduce the level of air pollution. One such step includes the banning of large diesel cars from the center of Delhi.1 However, Anumita Roychowdhury, executive director at the Delhi based Center of Science and Environment (CSE), believes that in order to reduce air pollution to WHO standards, environmental policy needs a thorough overhaul. 5 The CSE and the Central Pollution Control Board (CPCB) have made short term and long-term recommendations to India’s government

that include the following: 1) Make the National Ambient Air Quality Standards legally binding in all Indian cities and impose penalties on cities that violate them. 9 2) Regularly monitor PM air pollutants. Each day the public must receive specific health advisories and emergency smog/pollution alerts. 11 3) Control and cut increases in the total number of vehicles by increasing public transportation, utilizing non-motorized transport and compact city planning and restraining the use of cars. 9 Battery-driven vehicles should be employed and mass transit should be promoted. Carpools, pedestrian walkways and bicycles should be encouraged through the redesigning and development of communities.11 4) Prevent children’s exposure to diesel exhaust, which contains toxic fine particulates. School buses that use diesel should be eliminated and a cleaner fuel should be implemented.11 Where possible, relocate schools and child care facilities to areas that are at walking distance from children’s houses and away from roads with heavy traffic or other sources of air pollution. Further, offices and

Traffic at a standstill on a road in India Igor Ovsyannykov

YALE GLOBAL HEALTH REVIEW

Thomas Schoch

Children stand by the side of the street on their way to school.

shops should relocate closer to residential areas. 5) Mandate annual lung function tests and blood pressure tests performed in medical facilities set up at schools for all children ages nine and over in Delhi. These medical facilities should contain all the necessary equipment as well as trained technicians.11 6) Reduce industrial smoke stack emissions and increase the use of renewable power sources like solar and wind.1

Encouraging news from WHO data indicates that cities that commit to reducing air pollution are having successes. More than one third of the cities in low-and middle-income countries that made the commitment were able to reduce their air pollution levels by more than 5% in the last five years.1 Delhi and all other cities in India need to take action now to reduce air pollution and save both the environment and the long-term health of their people.

Roychowdhury says, “There is hard evidence now to act urgently to reduce the public health risk to all, particularly children….India will have to take aggressive action to reverse the trend of short-term respiratory and cardiac effects as well as long-term cancer and other metabolic and cellular effects.”9

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About half of the 4.4 million children who reside in Delhi already have irreversible lung damage.

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Rebecca Slutsky is a junior in Silliman College. Rebecca is a Molecular, Cellular & Developmental Biology major from New York. Contact her at rebecca.slutsky@yale.edu

Simon Fraser University

YALE GLOBAL HEALTH REVIEW

HEALTH POLICY

Is Fracking Safe? By Emma Phelps

VOLUME 4, NO.2

ydraulic fracturing, commonly referred to as fracking, is a drilling technique that allows the extraction of previously inaccessible natural gas from shale formations. The United States has experienced a fracking boom in the last decade. In February of 2016, the United States was producing 92 billion cubic feet of natural gas per day, much of it from fracking wells.1 The new technology has the potential to allow the United States to become a net energy exporter within a few years.2 Although fracking shows economic potential, new evidence indicates people living near fracking wells may suffer long-term health effects. Trying to balance the economic benefits of fracking with its health concerns raises important questions about how regulators should deal with the release of pollutants with unknown, but potentially serious, health consequences. Rather than creating an overarching policy, the federal government has left the regulation of fracking up to the states. Pennsylvania, Texas, Oklahoma and North and South Dakota have aggressively pursued the expansion of fracking, while New York has banned the practice due to concerns about the potential long-term impacts of exposure to pollutants that fracking releases into the water and air. While fracking produces large volumes of natural gas, it also requires huge inputs of fracking fluids. In the span of one

week, 11 to 19 million liters of fracking fluid, consisting of water, sand, and chemical additives, are pumped into a well to open and widen cracks in the rock deep underground.3 After being released from beneath the rock, natural gas flows back up the pipe, along with some of the fracking fluid. Flowback fluid—a mixture of naturally occurring compounds and water—also flows to the surface. This fluid is then pumped deep underground for storage, recycled, or taken to a wastewater treatment plant. Even though chemicals usually only make up two percent of fracking fluid, every well still uses between 150,000– 600,000 liters of chemicals.4 Due to a loophole in the Clean Water Act, companies are not required to release any information about the chemicals in their fracking fluids because it is considered proprietary information.5 Therefore, it is impossible to know exactly which chemicals are being used in any given area. Even if the chemicals were known, the health effects of many of the compounds are unknown. One study found that out of the 1,021 identified chemicals used in hydraulic fracturing fluids, only 240 had been tested for toxicity as of 2016.6 In addition to the possible toxicity of the fracking fluid, the flowback fluids also often contain radium and radon, both highly radioactive substances.7 Fracking and flowback fluids can contaminate surface or groundwater in several Erick Gustafson

A fracking well in Los Angeles, California.

ways, such as pipe leakage, chemical spills during well construction, and improper waste water treatment. Around nine percent of fracking wells have pipes that have failed at some point during operations, often due to faulty construction.8 These failures occur three to six times more often than those of conventional natural gas wells, and often lead to the contamination of nearby drinking wells.9 Another form of contamination occurs in the early stages of development, when each fracking well requires over a thousand truck trips to transport materials.10 These trucks often transport hazardous chemicals, which are then at heightened risk of spilling into streams and rivers. Flowback fluid can contaminate water sources when it is improperly treated in wastewater treatment plants and recycled into drinking water.9

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Should an industry with unclear, but potentially serious, detrimental effects on health be allowed to proceed?

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The contamination of water during the fracking process may affect the health of nearby communities. Residents near wells have complained of skin rashes, nausea, abdominal pain, respiratory difficulties, headaches, dizziness, eye irritation, throat irritation, nosebleeds, anxiety, and stress that demand further investigation.7 These short-term health effects, reported anecdotally by doctors in fracking boom areas, require further investigation to determine how their causes are related to fracking and how widespread they are. Many of the chemicals used in fracking are suspected to harm reproductive health. One study found that of those chemicals whose toxicity is known, 43% have negative effects on reproductive health.1 Some studies have demonstrated that populations living closer to a fracking well are at higher risk of pre-term births and birth defects.1 There is also a possible connection between fracking and increased incidence of miscarriage and low birth weight, but this relationship is less clear.1 These chemicals do not just affect women’s reproductive health; studies suggest that they may also reduce sperm viability, count and motility.1

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Elias Schewel

Chemicals used in fracking can impact reproductive health through various, often unclear, mechanisms. Some of the chemicals are known to be estrogenic, which means they mimic the structure of estrogen, a natural hormone that is particularly important for regulating the female body. Others may affect receptors for estrogen and other hormones. Both of these effects can lead to infertility or cancer by disrupting the regulation of estrogen that is necessary to control the female reproductive system. Other chemicals are suspected to damage DNA in the egg and sperm, which can increase the risk of birth defects.1 Although the media most commonly publicizes concerns about water safety, fracking also results in air pollution. One study estimated that in Pennsylvania, air pollutant emissions associated with shale gas extraction resulted in $7.2 to $32 million in region-wide environmental and health damages in 2011 alone.10 Fracking wells often release trapped methane, benzene, carbon monoxide, hydrogen sulfide, nitrogen oxides, particulate matter, sulfur dioxide, and volatile organic compounds (VOCs) from beneath the shale rock, in addition to natural gas, all of which are known respiratory irritants. Benzene is also a human carcinogen. Polyaromatic hydrocarbons (PAH) and benzene, which

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are both respiratory irritants and carcinogenic, have been found at illegal levels even at distances over a mile away from fracking wells.10 There are also high levels of ground-level ozone, another respiratory irritant that can increase the frequency of asthma attacks, around wells.11 Studies have shown that people who live near wells are at increased risk of asthma attacks, most likely due to fracking-related air pollution.3 Workers at fracking wells are at particularly high risk of poor health due to increased exposure to toxic chemicals. In particular, occupational exposure to respirable crystalline silica is associated with numerous health effects, including silicosis, lung cancer, tuberculosis, autoimmune diseases, and kidney disease.9 The longterm health effects of fracking on workers are still unclear, however, because it has only been a widely-used practice for ten years.5 With hundreds of thousands of fracking workers in the US, though, any occupational health hazards that may occur are likely to be expensive to treat.12 The long-term effects of fracking on general populations are also unclear, but are likely to include increased cancer rates. Many of the chemicals that have been detected in the drinking wells and air sur-

rounding fracking wells are known carcinogens, but because cancer can take years to develop, their effect on cancer rates in these regions is still unknown. In addition, not all of the chemicals that are commonly used have been tested for carcinogenic effects. Even if all of these untested chemicals were harmless in isolation, multiple chemicals can interact in unknown ways in the body, sometimes amplifying the carcinogenic effect.8 When chemicals are tested for toxicity, they are tested individually and so their interactions with other chemicals are not investigated. This systematic flaw in scientific toxicity testing causes problems for determining the exact effects of drinking water that is polluted with multiple fracking fluid chemicals. Chemical interaction is only one field of study where there is an acute need for more research into the health effects of fracking. The potential reproductive health impacts described earlier are not proven because most studies have been relatively small-scale. These studies are suggestive of health hazards, but are not conclusive.7 Conducting studies that prove causation, and not just correlation, is expensive and often time-consuming. In order to protect the health of residents in fracking areas, however, it is necessary to know exactly what risks they face.

Joshua B. Pribanic

YALE GLOBAL HEALTH REVIEW

In addition to physical health, the development of the fracking industry can impact the mental and social health of communities. Most of the new extraction areas are in very rural parts of Pennsylvania, the Dakotas and Texas. The influx of workers creates shale gas boomtowns and increases industrial pollution within the area. Many residents express concerns about sleep disruption from increased traffic, and increasing levels of drug use and sexual assault.9 These issues, combined with a feeling of being powerless to stop the changes, can lead to increased chronic stress. 10 Although fracked natural gas is often touted as a cleaner and more environmentally friendly alternative to coal and oil because it produces less carbon dioxide when burned, most measurements do not account for methane leakages that occur and the number of truck trips that are required for fracking wells.13 Fracking releases twice as much methane, a potent greenhouse gas, from leaks as conventional drilling does.4 When total greenhouse gas emissions are considered, fracking may not be more environmentally-friendly.13 The high carbon emissions from the extraction and combustion of fracked natural gas are contributing to anthropogenic climate change, which is projected to have serious health impacts, including the spread of mosquito-borne diseases, increased malnutrition, increased rates of asthma, and increased mortality due to higher incidence of heat waves, droughts, floods, wildfires, and other natural disasters.14 When considering the health impacts of fracking, it is important to bear in mind the future impacts of the combustion of fossil fuels, which will affect communities around the world. Fracking presents a quandary for lawmakers. Should an industry with unclear, but potentially serious, detrimental effects on health be allowed to proceed? Should a ban only be implemented once there is conclusive evidence of harm? Within the United States, individual states have answered these questions differently. For example: although New York and Pennsylvania both lie on top of the Marcellus shale formation, their governments have regulated fracking in completely opposite ways. In 2008, New York implemented a temporary moratorium on fracking while the health and environmental departments investigated its impacts. After seven years of study, the decision was made to extend the ban. The Department of Environment Commissioner cited “significant adverse impacts to land, air, water, natural resources and potential significant public health impacts that cannot

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be adequately mitigated” as the reason for the decision.15 New York’s ban is in line with the precautionary principle of environmental justice, which states that if a substance is suspected to be hazardous to human health or the environment, it should be banned until proven safe.16 In contrast, neighboring Pennsylvania has aggressively pursued fracking. There are currently 7,788 fracking wells in the state and the number is projected to continue to increase.17 This industry expansion has had significant impacts on the southwestern and northeastern parts of the state, formerly rural areas that are, in effect, experiencing accelerated industrialization. Fracking employs 33,000 people in the state and financially benefits those who own mineral rights and lease their land to fracking companies.17 Residents, however—particularly those in Appalachia, which has a long history of extractive industries leaving residents poor—are wary. Pennsylvania’s environmental policy is based on the principle that chemicals may be used in the environment until scientists have biomedical proof that they cause harm to human health. This means, however, that they are gambling with health; if fracking has as severe a health effect as some studies suggest, it may dramatically increase rates of cancer, asthma and reproductive disorders before being proven to cause conclusive harm. These diseases are expensive to treat and could offset some of the purported economic benefits of fracking. Residents in fracking areas have raised concerns about environmental justice. A fundamental principle of environmental justice states that there should be an equal distribution of environmental harms across the entire population.19 In states, such as Pennsylvania, Texas, Oklahoma and the Dakotas, where fracking has been allowed at the state level, the decision-making power about whether fracking companies come into a particular community lies with those who own mineral rights. Since not all residents own the mineral rights to their land, this means that some of those who are most affected by the pollution have no power to stop fracking taking place in their community. Additionally, only those who own mineral rights experience direct economic benefit, in the form of royalties paid by fracking companies. Everyone living near a fracking well is recommended to test their drinking wells for hazardous pollutants every six months, but in rural areas, where many people rely on wells for water, testing can be prohibitively expensive.10 Therefore, residents who do not own mineral rights may disproportionately suffer negative economic and health effects from fracking.

The city of Denton, Texas is an illustrative case study. Denton is an urban area that sits on top of the Barnett Shale region and was one of the first cities where fracking was tested. Homeowners living in close proximity to drill pads have filed numerous complaints about noise and light pollution, and report increased nosebleeds, nausea, headaches and other symptoms. The majority of those who benefit directly from fracking, however, do not experience these negative effects because 61.4% of the mineral rights owners in Denton are not residents of the city.19 This means they receive direct compensation for fracking but, since they do not live in close proximity to the wells, do not experience the health risks. Because the number of mineral rights owners living in homes close to fracking wells is much smaller than the number of those without mineral rights, the majority of those at risk of potentially severe health effects in Denton both exercise no power over the decision to let fracking companies build wells and receive no direct financial compensation for the risk to their health. Fracking presents an unclear, but likely significant, threat to human health. Its effects are beginning to be studied more in-depth, but many people living in fracking boom areas are currently acting as human experiments. The long-term effects of living with fracking-contaminated drinking water and air pollution may not be known for several decades and all current studies are complicated by the shocking fact that companies are not required to release information about the mixture of chemicals that they use. Those who most benefit from fracking usually do not live in the vicinity of a well, and are therefore not at risk from the many possible health effects. Legislators have an obligation to look closely at these risks before allowing fracking to proceed unquestioned. They are responsible for the wellbeing of the communities affected by fracking. Legislators play a particularly key role because those most vulnerable to the effects of fracking are often powerless to regulate it. In addition, lawmakers need to consider the effects that climate change, caused by the combustion of the fossil fuels extracted through fracking, will have on the health of communities around the world. www

Elizabeth Li is a sophomore from the United Kingdom majoring in Ecology and Evolutionary Biology. Contact her at emma.phelps@yale.edu.

MENTAL HEALTH

MENTAL HEALTH: By Holly Robinson

PTSD in Children and Adolescents:

Equivalent Exposures, Distinct Diagnoses

ne in four children living in the United States experiences a traumatic event before reaching adulthood.1 These distressing encounters, which include experiences from sexual abuse to natural disasters, affect the mental health of the individual as well as the overall wellbeing of the population. Because they are still in their formative years, children succumb more easily to negative experiences than adults. Childhood trauma is associated with depressed IQ, lower reading ability, increased school absences, and decreased graduation rates.1 Negative experiences can also cause post-traumatic stress disorder (PTSD) when trauma is severe or prolonged, or when children lack social support or necessary coping mechanisms. PTSD occurs with high levels of comorbidity, such that over 75% of those who suffer from PTSD struggle with additional mental health problems, including anxiety and depressive disorders.1 Studies show that three to 15% of girls and one to six percent of boys who have experienced trauma develop PTSD.2 Those who work in childcare and educational settings often lack sufficient

awareness of and training for children’s mental health and their risks for developing PTSD. The profound negative effects of this mental health condition should, however, concern schools, especially after large-scale traumatic events. The term “PTSD” may conjure images of returning veterans, war-torn countries, and extreme violence, all of which involve an adult male exposed to unimaginable tragedies overseas. Such cases certainly do exist, but we must also consider how PTSD affects traditionally neglected populations that also face various types of violence. These typically neglected populations include women and children. Recent research has shown, however, that the upsetting events that cause PTSD do not always inspire the same amount of awe and fear secondhand. Unaffected populations may not appreciate how a seemingly typical occurrence may cause equal damage, especially within more vulnerable populations. Natural disasters, motor vehicle crashes, and the suicide of a close friend all elicit stress responses severe enough to cause PTSD. No direct correlation ex-

ists between the “severity” of a trauma and the reaction that follows, since many other factors affect the stress response of each individual. In fact, accounts of firsthand trauma have the power to cause PTSD. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) requires that, in order to receive a diagnosis of PTSD, the patient (1) directly experiences the event; (2) witnesses the event; (3) learns that a close friend or family member has experienced a traumatic event; or (4) experiences repeated or extreme exposure to aversive details of the traumatic event. 3 Although men experience more trauma in their lifetimes than women, the latter, perhaps surprisingly, are more likely to develop PTSD. In addition, in the United States, five percent of adolescents have met criteria for PTSD in their lifetimes, even though they may not have experienced the horrors of war.4 Children and adolescents thus comprise an invisible population of PTSD sufferers, overlooked not only by the health care system, but also by groups such as the education system that were designed to

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Infrogmation

A home destroyed in Hurricane Katrina.

help them succeed. When the concept of PTSD first emerged in the 1980s, researchers believed that it could not apply to children and adolescents in the first place.5 The diagnosis of PTSD expanded to include children and adolescents only in 1987. 6 Even within the populations of children and adolescents, however, responses to trauma vary. Children with a history of trauma in addition to the specific triggering experience develop PTSD at higher rates than their peers. Similarly, preexisting psychiatric disorders and a family history of psychopathology place children at higher risk for developing PTSD after a traumatic incident. 3 Due to the developmental state of children, they are at higher risk of developing PTSD than adults. One study showed that, after the same exposure to trauma, 57% of adults developed PTSD, while 77% of children also received the diagnosis.7 Children may experience PTSD differently than adults. The DSM-V has, for the first time, separated the experience of PTSD for those age six and under from the experience of adults. 8 The inclusion

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of this subgroup marks an important step forward in the consideration and treatment of PTSD in children. Because verbal expression skills begin to emerge during the first six years of childhood, this subgroup requires diagnostic criteria that take into account their cognitive and verbal expression skills, for example, focusing more on behavior than on verbalization of the traumatic event. 9 Parents and clinicians look for behavior such as disturbed sleep patterns, separation anxiety or clinging behavior, and conduct disturbances.7 Additionally, the diagnostic criteria must plan for increased sensitivity when working with children who may not yet be able to fully conceptualize the true extent of their experiences. 9 Certain criteria, such as a “sense of a foreshortened future” included in the adult diagnosis also fail to distinguish traumatized children from their peers.9 The adult diagnostic criteria require that the re-experiencing symptoms manifest as recurrent, intrusive, and distressing; however, in young children, re-experiencing symptoms may manifest in a wide variety of emotions, including excitement. Thus, the DSM-V

has removed the distress component of the diagnostic criteria for those ages six or younger. 9 Children now only need to meet one criterion, rather than three, in order to receive a diagnosis of PTSD. Children also exhibit unique symptoms when experiencing episodes of post-traumatic stress, such as “time skew” and “omen formation.”4 “Time skew” occurs when children attempt to narrate their trauma, but incorrectly sequence the events in their account. Children also often believe in the presence of warning signs that may have predicted the negative occurrence; as a result, they may become hyper-alert in an attempt to identify warning signs or omens of future traumatic events in order to avoid further suffering.4 Children suffering from PTSD may also reenact their trauma in drawings or verbalizations, or engage in post-traumatic play. In post-traumatic play, the child compulsively repeats an aspect of the trauma but cannot relieve her anxiety. 4 We must demand that all childcare-related professions require ongoing train-

ing in PTSD and related disorders in children in order to gain a better understanding of the unique manifestations of PTSD in children. Parents often underreport PTSD in children, as well, since they do not realize that their children might experience as much or more distress than they. 7 Educating parents, as well as childcare professionals, on the signs and symptoms of PTSD can increase awareness and reporting behavior, especially after large-scale traumatic events such as a school shooting or a natural disaster. This preparation ensures that children receive the mental health care they need in order to overcome adversity, thrive in school, and grow into healthy and productive members of their communities. Without such care, children may suffer from stunted developmental and educational growth in the face of overwhelming amounts of stress. Traumatized children are also at risk of developing personality changes, suicidal behaviors, and other psychiatric disturbances such as depression.5 As research on PTSD in children expands, innovative treatment options have begun to enter mainstream practice. Following large-scale traumatic events, schools serve as an ideal setting for interventions with children. 10 By establishing mental health interventions in schools, healthcare systems can increase the number of children who have access to mental health care. This practice will especially benefit locations where mental health care is not widely available, such as rural or low-income settings, or schools with underserved ethnic minority populations. Additionally, studies

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Children and adolescents thus comprise an invisible population of PTSD sufferers, overlooked not only by the healthcare system, but also by groups such as the education system that were designed to help them succeed.

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have found that children and adolescents spontaneously mention their trauma experience less than other age groups.10 Schoolbased mental health care provides children with an opportunity to discuss and verbalize their trauma in a space that feels familiar and safe. School interventions can also leverage teachers as a resource, since educators may be particularly attuned to behavioral changes following traumatic events. After Hurricane Katrina essentially demolished New Peter Murphy Orleans and surrounding areas in August of 2005, researchers implemented and analyzed school-based mental health treatment in three New Orleans schools.10 They found that over 60% of students between grades four and eight exhibited symptoms of PTSD, a dramatic increase even after past history of trauma had been taken into account. The researchers introduced two different types of cognitive behavior therapy, the first-line treatment standard for PTSD, to students who had not already sought mental health care. They compared an innovative method called Cognitive Behavior Intervention for Trauma in Schools (CBITS) to the more traditional Trauma Focused Cognitive Behavior Therapy (TF-CBT).10 CBITS, conducted in schools in group settings with only children, focused more on the school setting, while TF-CBT took place in a clinic and parents were invited to attend counseling sessions. The results of this study underline the important role that mental health interventions in schools may play in buffering the effects of stress and mitigating the symptoms of PTSD in children. In New Orleans schools, 98% of children assigned to CBITS successfully initiated

treatment, while only 23% of those assigned to TF-CBT began treatment, despite efforts to provide free taxi service and childcare to those randomized to the TF-CBT group. While some children in each intervention group failed to complete the full intervention (10 sessions for CBITS and 12 sessions for TF-CBT), 91% of those randomized to the CBITS group completed the full intervention, while only 15% of those randomized to the TF-CBT group attended all twelve sessions. Children who attended counseling sessions within either intervention showed improved PTSD scores at six months, a statistic that demonstrates the importance of counseling more generally. CBITS, however, achieved stronger scores than TF-CBT.10 Child psychology experts revisited the importance of school-based mental health interventions after the Sandy Hook Elementary School shooting in December 2012, which took the lives of 20 children and six adults in Newtown, Connecticut. School shootings pose particular concern for both mental and physical health, because such extremely violent episodes disrupt the essential need for safety and security held by both chil-

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dren and adults. 11 Following the shooting, the state government appointed an advisory committee to research and provide policy recommendations about issues such as firearm permits and registration, safe school designs, and mental health care. 11 The March 2015 final report issued by this advisory committee called for schools to offer screening and referrals for mental and behavioral health services. The advisory committee also suggested that Connecticut public schools partner with pediatric healthcare providers to bolster the mental health resources offered by schools, and to increase the number of psychiatrists, social workers, and guidance counselors available at schools.11 Such efforts transform the school from the site of trauma to a site of healing, allowing children, teachers, and administrators to regain a sense of normalcy while still remembering the tragedy that occurred. Another promising avenue of schoolbased mental health care recommended by the Sandy Hook Advisory Committee is the development of curricula focused on social and emotional learning (SEL). SEL has been proven to positively affect childrenâ&#x20AC;&#x2122;s development and academic

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performance.11 By teaching students how to name and identify feelings, SEL curricula help children and adolescents to cope with their difficult emotions. SEL curricula also help children develop positive social relationships, which can serve as buffers to future stress. This crucial preventive care could prove essential in the event of trauma and toxic stress, but school systems often neglect emotional learning and wellbeing in favor of rigorous and comprehensive academic curricula.11 Teachers and students, however, need such training to meet their emotional needs in order to prepare for upsetting and traumatic events. While this essay examines research and policy recommendations for certain types of school-based intervention after two specific traumatic events, its results extend to other negative experiences. Initiation of peer group therapy following large-scale traumatic events may increase access to care and reduce stigma about mental health treatment. By placing these interventions within schools and allowing children to see the similar struggles of their peers, schoolbased health workers can foster a culture of mental health and wellbeing. The success of school-based mental health interventions should also open up conversations about training for teachers and administrators, since they may need to handle large-scale tragedies and to identify early signs of PTSD and other mental health issues in children through formal screening processes. Since symptoms of PTSD may not develop immediately after a traumatic event takes place, educators must monitor children in the weeks and months following a tragedy. 1 Schools can better prepare for the onset

of a large scale traumatic events by training teachers about the signs and symptoms of PTSD before such events take place. In contrast, educators will find it difficult to immediately implement such programs in the aftermath of a tragedy, since they will feel greatly affected by such events as well. The Sandy Hook Advisory Committee, for example, suggested ongoing professional development regarding strategies to bolster learning for grieving students and identification of children who may need additional mental health resources or referrals.

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By teaching students how to name and identify feelings, SEL curricula help children and adolescents to cope with their difficult emotions.

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The consequences of a traumatic event extend far past its immediate aftermath, and post-traumatic stress disorder, as well as and other mental health problems, can affect anyone in the population, even if they have not experienced trauma firsthand. PTSD awareness must spread beyond veterans and war-related services. PTSD affects children and adolescents, women and men, military personnel and civilians. If we are to take the disease and its many consequences seriously, we must push for better integration of mental health care into primary care programs and school systems in order to ensure that everyone can easily receive treatment in the event of trauma. After all, there is no health without mental health. www

Holly Robinson is a senior in Branford College double majoring in Russian and Anthropology. Contact her at holly.robinson@yale.edu

UGANDA:

FIELD WORK

Implementation Research and Viral Load Monitoring in Kampala, Uganda

“T

By Isla Hutchinson Maddox

his departure from a ‘Cinderella success story’ in Uganda has brought renewed energy, funds, and focus to the country’s greatest health burden, HIV/AIDS.

HIV/AIDS AND VIRAL LOAD MONITORING IN UGANDA At the 21st International AIDS Conference in Durban, South Africa in July 2016, a prevailing sense of optimism filled the room as thousands of the brightest minds in HIV/AIDS research and care flooded the Durban International Convention Centre. This annual conference provides a unique forum to discuss recent scientific developments, to examine necessary policy change, and to collectively reflect on differing perspectives on HIV across the globe.1 This year’s conference culminated in a rallying cry to adopt the UNAIDS “Fast-Track” strategy, which seeks to end the deadly epidemic by the year 2030.2 Many, however, fear that the convention only served to sensationalize progress and distract from many unaddressed social and economic barriers to care. “It is clear that the global rhetoric around the current ‘end of AIDS’ needs to be matched with an equally robust reality check,” wrote scientists Chris Beyrer, Linda-Gail Bekker, and Françoise Barrè-Sinoussi in Spotlight, a South African publication that monitors the nation’s TB and HIV response.3 My own “reality check” came this summer when I accepted an internship to assess the role of viral load monitoring at the Infectious Diseases Institute (IDI) in Kampala, Uganda.

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Uganda, “the pearl of Africa,” is a landlocked East African country with a population of over 37 million people. In the 1990s, HIV/ AIDS rates decreased dramatically in Uganda when Yoweri Museveni, the longstanding president, adopted a multi-sectoral approach that emphasized HIV/AIDS education and public awareness campaigns. In recent years, however, there has been an uptick in the number of infections, which many attribute to government complacency after this initial success.4 In 2015, UNAIDS reported that HIV prevalence rates for adults aged 15 to 49 stood at about 7.1%, with the majority of these infections clustered among at risk populations, such as young adults, commercial sex workers, men who have sex with men, and discordant couples (one partner is HIV+ and the other is HIV-).5 This departure from a “Cinderella success story” has brought renewed energy, funds, and focus to the country’s greatest health burden.5 A primary objective in Uganda since the renewal of PEPFAR (President’s Emergency Plan for AIDS Relief) in 2008 has been to expand access to treatment beyond the 57% of HIV+ adults who now receive some form of antiretroviral therapy (ART).5 Although it is essential to tackle the remaining 43%, it is equally important to ensure that hospitals and clinics deliver the best quality patient management when HIV+ adults

do receive ART.6 In regards to this secondary goal, the strength of the HIV treatment cascade, a model that “outlines the sequential steps or stages of HIV medical care from initial diagnosis to achieving the goal of viral suppression,” becomes an especially important measurement of optimal medical care.7 There are many interventions along this cascade of care that aim to evaluate and to reinforce the progress that a patient makes during his or her path to viral suppression. The World Health Organization (WHO) defines viral suppression as less than 1000 copies of the HIV RNA virus per milliliter of blood.8 Many clinics invest in both CD4 counts and viral load (VL) monitoring as preliminary indicators of treatment failure or suboptimal adherence.9 Some researchers, however, herald VL monitoring as a wiser investment since it is more effective at detecting subtleties in immune response.9

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MĂŠdecins Sans FrontiĂ¨res

For example, research has shown that people with the same CD4 cell counts may have different viral loads, and those with a higher VL are more likely to develop symptoms of an opportunistic infection than those with a lower VL.9 VL monitoring, therefore, has taken center stage in recent years in patient management: preventing unnecessary switches to second-line therapy and ensuring that resistance testing, adherence counseling, and VL rechecks remain crucial interventions along the cascade of care.1011 VL testing is like an alarm that alerts physicians that the current drug regimen is no longer working for a patient. The course of HIV drugs may be simply rendered clinically ineffective or the patient may not be adhering properly to his or her daily cocktail of first-line drugs: AZT, a nucleoside reverse transcriptase inhibitor, and a non-nucleoside reverse transcriptase inhibitor.12 If adherence is suboptimal, this may allow for the accumulation of deleterious mutations

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among the proliferating HIV virion cells and subsequently lead to a drug resistant strain of infection. VL monitoring, therefore, forces the physician to focus on and better tailor care for those patients who are unable to achieve viral suppression, exhausting all possible interventions before switching a patient to a second-line course of therapy that is not only more toxic but also more expensive.13 In 2014, UNAIDS created a stepping-stone along the path to eradication with the 90-90-90 global agenda: 90% diagnosed, 90% on treatment, 90% virally suppressed.14 At the International AIDS Conference, there was an overall consensus that global gains indicate a gradual progression towards this target; however, many sub-Saharan African countries have criticized the feasibility of this goal recently with the deadline fast approaching in just four years.15 Viral load monitoring, a central component of

the viral suppression portion of the 90-90-90 goal, is an especially resource-intensive practice that is of greatest consequence in the most resource-deprived settings across sub-Saharan Africa. Only a few nations, including South Africa, Botswana, and Namibia have scaled up VL programs across the country, while Uganda is still in a phase of data collection and continues to conduct feasibility analysis in both urban and rural parts of the country (Figure 1).16 This analysis or research raises a myriad of questions. Does VL monitoring realistically and efficiently fit into Ugandaâ&#x20AC;&#x2122;s cascade of care? For those clinics where it is currently in use, are physicians properly utilizing it? Do certain trends emerge along this cascade of care that might bring to light gaps in patient management? Implementation research, therefore, becomes essential to answering these questions and ultimately determining whether this resource-intensive practice is worth the investment.

of adherence to treatment among the clinic’s general population. As a result, we refined our research to analyze the care of young adults, aged 18-25. Globally, young adults have been identified as an especially vulnerable population.22 Sub-Saharan Africa alone accounts for 70% of the world’s new HIV infections among young people aged 15-24.22 They are more likely to be inexperiInternational AIDS Society enced with regards to strenuous ART Figure 1: This map shows the maturity and scope of viral load monitoring drug regimens, programs across Sub-Saharan Africa. While southern African countries engage in risky including South Africa and Botswana have adopted advanced programs, sexual behaviors, countries in East Africa including Uganda and Tanzania are still in the stagand to have higher es of feasibility analysis, requiring thorough implementation research. rates of suboptimal adherence comUganda has, therefore, shifted research pared to older HIV patients.19 A meta-analysis priorities away from the assessment of new conducted in 2013 reviewed published litermedical technologies and towards implemen- ature on HIV among adolescents and young tation research in order to determine whether adults (AYA) and found that only 62% were the technologies currently in play are effective. adherent to ART drug regimens, far below Implementation research is a relatively new number needed to achieve the third 90-90-90 field of health research that evaluates the prac- target.20 An internal assessment by the Quality tice of medicine – not from the confines of a Assurance Office at the Infectious Disease Insterile, well-controlled laboratory - but in real stitute had found that about 84% of the general world conditions.21 Public health experts and patient population (N = 6438) had achieved viscientists can work together to not only build ral suppression over the course of about a sinnew and more refined technologies but also to gle year, therefore, we used this as our benchensure that they will be properly utilized “on mark – initially hypothesizing that the young the ground.” Uganda is in the stages of assess- adult patient body would present much lower ing the quality of VL monitoring programs numbers. currently in place at some of the nation’s largOur team conducted a retrospective cohort est clinics in order to determine if one might serve as the most efficient and practical mod- study of young adult patients undergoing rouel of care in this developing country. The In- tine VL monitoring between December 2014 to fectious Disease Institute (IDI) at the heart of July 2016. As per World Health Organization Uganda’s capital, Kampala, regularly serves guidelines, a VL test is conducted every 6-12 8,000 HIV infected patients and therefore pro- months for all patients on ART.21-22 To assess vided the perfect backdrop to conduct our re- the effectiveness of IDI’s VL monitoring protocol, data were extracted from a clinician’s “desearch this summer. cision form” that is filled out for those patients VIRAL LOAD MONITORING IN with a detectable viral load (>1000 copies/mL). UGANDA: This clinician form lists a number of possiTHE BASICS OF OUR STUDY ble directions for patient care that essentially builds IDI’s stepwise protocol for a detectable Previous studies conducted in 2015 at IDI patient, similar to an HIV treatment cascade. had already examined the importance of VL Some physicians, for example, immediately monitoring as a litmus test or measurement refer patients to adherence counseling after a

detectable viral load, reflecting suspected suboptimal adherence. Other patient charts are referred to a switch meeting: a multidisciplinary meeting unique to IDI, attended by counselors, nurses, pharmacists, and clinicians each week. During these hour-long switch meetings, counselors present the case history of patients who have been unable to achieve viral suppression. The team then makes a comprehensive decision regarding the status and care of a single patient. We calculated the median turnaround time for various interventions along the cascade (e.g. the time between detectable viral load and switch to second-line) in order to determine how well IDI managed patient care from day to day. Turnaround time is an especially important measurement along this treatment cascade as a number of patients may fall through the cracks with little to no safeguards in place to get them back on track and returning regularly at the clinic. Between December 2014 and July 2016, 252 young adult patients were tested for VL at IDI, of which 48 (19%) had a VL >1,000 copies/mL (viral load detectable). In total, 370 VL tests were performed, of which 81% (300) were undetectable. Figure 2 summarizes the actions taken for those 48 patients who collectively had 70 detectable VLs over the course of the study with green boxes highlighting important trends. Of the 48 patients with a detectable VL, only 21 switched to second-line treatment (43.8%), with one patient switching twice over the course of the study. In an attempt to prevent unnecessary switches, 10 of these 22 switches (45.5%) occurred only after adherence counseling and a VL recheck. Eleven switches (50.0%) occurred following a switch meeting. Of those 21 patients who switched, 16 attended at least one adherence counseling session following the switch in order to highlight the necessity for proper adherence. Four patients (50.0%) who received a resistance profile switched to a second-line regimen, often prior to receiving resistance results. The median time to switch from the date of the initial VL test was 146 days (IQR: 91-209). Throughout the course of the study, 22 patients (8.7%) qualified as lost to program (LTP), signifying that their last clinic visit was more than 3 months before the study’s termination. A majority of these LTP patients however had an initial undetectable VL (n=14, 63.6%), while 8 (36.4%) had an initial detectable VL. Three patients (1.2%) were unable to be tracked, 2 patients (2.4%) died, and 4 patients (4.8%) transferred out of IDI during the study period. At the end of the study, 21 (43.8%) of the orig-

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inal 48 patients with a detectable VL remain on first-line ART and continue to attend IDI regularly. DISCUSSION While the third 90-90-90 target set by UNAIDS provides a lofty goal to strive towards with regards to patient care and VL monitoring, this study found that young adults, an at-risk population, came close to this target with over 81% of patients achieving viral suppression. As clinics strive to close this gap, it is essential that those clinics similar to IDI apply additional safeguards when treating patients. In order to ensure that this target is feasible for all populations, certain protective measures should be put in place, along with the cascade of care, that take into account potential risk factors that might impede optimal adherence. Qualitative research, therefore, should be incorporated into future studies in order to better assess what circumstances or factors might cause to a patient to drop out of treatment or to adhere improperly to their drug regimen. Variables might include sex, age, education, religion, number of current sexual partners, and marital status. Delaying switches to second-line therapy appears especially important for young adult patients who are often ART naïve, adjusting to a daily drug regimen, and facing internal and external stigma. During this study, less than half of patients with a detectable VL switched to second-line treatment, suggesting clinician’s suspicion of suboptimal adherence. For these detectable patients, adherence counseling may play a crucial role in preventing unnecessary switches to second line therapy and helping patients achieve viral suppression. Complementary interventions and a stringent stepwise protocol that recognizes the potential leaks in the cascade of care are especially important for this transient, vulnerable population. One component along this cascade of care that was called into question during this study was the role of resistance testing in patient management. Blood samples for resistance profiles are often unable to be analyzed at an in-house location and are sent as far as the United States. Consequently, the turnaround time is great. Patients often switch to second-line prior to receiving the resistance profile or become lost to program. The young adult population is more likely to exhibit suboptimal adherence and therefore accumulate resistant mutations, and data suggest that physicians switch these patients regardless of resistance testing results.23Resistance testing therefore may not be the most decisive intervention in a resource-low

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setting especially when routine VL monitoring is so resource-intensive and has proven to be a more practical investment. Although this study is in part strengthened by the fact that it follows patients through the entire process of VL monitoring at a centralized location, a number of limitations arise when performing such condensed and streamlined research. Primarily, the generalizability of these findings may be limited. Uganda has a relatively young ART / VL monitoring program; therefore, these findings might hold little external validity when compared to naïve programs in other Sub-Saharan countries or when compared to more robust programs, like those in South Africa.24 The study’s cohort was limited to young adults who attend IDI; therefore, the sample size was small and only tracked for a period of 20 months.

“

lungs painfully ached to breathe. The doctors, on the other hand, saw patients. This is not to minimize how the physicians approached each person in need; however, they as a community needed some form of humor in order to continuously provide the critical care that they do. There is obviously stigma surrounding HIV in Uganda; however, here at IDI it is not apparent. This is their job, and this is their reality. When I traveled to Africa for the first time, my understanding of the continent was the one that is plastered on billboards and pictured in advertisements for NGOs, UNICEF, and Save the Children. Living in Uganda, however, has allowed me to step outside of the white-washing treatment and homogenization that the Western media gives this continent as a whole. I had all these preconceived notions about what Africa would be like. Yes there is extreme poverty, hunger, and rampant disease; and there are as many posters to remind you to wear a condom as there are sushi joints in New Haven, but there are also millions of happy people – that love Uganda; that have – what we would call – normal lives. They go to bars and look forward to the movies on Monday nights and obsess over Facebook and Instagram likes. Although this article doesn’t explicitly serve as a plug for Yale International Coordinated Internships, I believe that my experience abroad this summer was invaluable. In recent years, global health as a discipline has gained ground as thousands of public health experts, scientists, and physicians flock to this field of work. While it is a remarkable feat, it is essential that studies remain as closely grounded to the field as possible. With this perspective and focus, it will serve as a constant reminder that these research subjects or patients are real people, not merely figures or statistics. It is one thing to study “HIV/AIDS in Africa” from the confines of the classroom, but another thing entirely to witness its toll on real people.

Living in Uganda, however, has allowed me to step outside of the white washing treatment and homogenization that the Western media gives this continent as a whole.

This study evaluated the effectiveness of IDI’s protocol alone and did not use a control group to compare the strength of other VL monitoring protocols. Further research must be conducted to not only strengthen existing protocols but also to determine the best possible cascade of care when managing HIV+ patients. In addition, expanding access to ART for all HIV+ patients will ensure that more patients regardless of location can begin this cascade of care and achieve viral suppression. This research ultimately reflects the importance of complementary interventions such as adherence counseling and viral load rechecks when managing HIV+ patients especially within the young adult population. In order to ensure that the 90-90-90 target is met in the next four years, it is essential to continue research at IDI. FINAL REFLECTIONS ON HIV/AIDS AND UGANDA This summer, I was forced to not only confront my conception of HIV/AIDS – a disease that I have studied furiously in the classroom, reading countless policy briefs and UNAIDS reports - but also to address my conception of Uganda. While working at an HIV clinic, it was unnerving at times to hear how casually physicians and counselors spoke about this horrifying disease that I was witnessing for the first time. I saw people on the brink of death - severely malnourished as their diaphragms and

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www Isla Hutchinson Maddox is a senior in Berkeley College majoring in History of Science, Medicine, and Public Health. She can be contacted at isla.hutchinsonmaddox@yale.edu

SUSTAINABLE DEVELOPMENT

BANGLADESH: Securing Water For Food

Transforming the Narrative of “Mini-Deserts”

ituated on the Ganges Delta and the Bay of Bengal, the nation of Bangladesh is constantly devastated by flooding from the 230 rivers surrounding it. Pockets of farming villages often have their growing crops and farmland destroyed by the torrential water, forcing families to leave in search of new villages and livelihoods. In the past year, over 100,000 women, men, and children were displaced because floods had destroyed their food sources.1 But this does not have to continue. Although the natural course of Mother Nature cannot be altered, some of its destructive aspects can be transformed into processes that benefit people’s lives. Practical Action, an international development charity, aspires to turn Bangladesh’s floods from agricultural banes into farming aids using a technology called sandbar cropping. This innovative, low cost agricultural technique has already helped nourish and restore several farming villages. In the winter, Bangladesh’s rivers undergo major recessions, leaving thousands of hectares of sandbar. These large, barren

lands are covered with sand on top of silt. Practical Action’s sandbar cropping innovation takes advantage of these lands, producing vast harvests of crops from what would otherwise be ‘mini-deserts.’ This is how sandbar cropping works: first, a pit one meter deep and one meter in diameter is dug into the sandbar. Then a jute sack made of porous fibers is filled with a compost (cow dung, soil, and water) and placed into the hole. Next, 5 to 6 seeds are sown into the sack and grown for about three months, and voilà! The harvest commences. This inexpensive and accessible process allows farmers to plant seeds in previously fallow sandbars, because it allows their crops to access fertile silty layers, while keeping the crops inside easy-to-monitor and easy-to-access capsules.2 Because of Bangladesh’s volatile climatic conditions, pumpkins are the primary crop of Practical Action’s project, as they maximize profit over time.2 Other low-maintenance crops such as lettuce and squash are also viable options that the organization is working to expand other countries.4 Their innovation is unique in that it requires no special me-

By Minh Vu

chanical input, but rather is a simple and low cost technique that can create tangible improvements for affected village communities. Over the past year, through a series of initiatives by the Rangpur Division and the United Kingdom Government, Practical Action has outreached the sandbar cropping technology to over 32,000 households whose farms and crops had been lost through river erosion, making arable over 9,000 km2 of sandbar land, and leading to the production of one million kilograms of pumpkins.1,3 To see the impact of this technology in a real family, consider the story of Mohammed Saiful Islam. From when he was age 3 to age 13, he and his family were displaced, until they reached a flood protection embankment in Haripur in 1992. There, Mohammed found a job as a laborer, but his low wages could not sustain the family’s nutritional needs.1 Practical Action stepped in. Along with 3,200 other families, Mohammed received training, seeds, and compost from the organization’s ally AKOTA to start new homes and farms. In his first year of sandbar cropping, Mohammed recounts being “astonished” at

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the pumpkin harvest he made: he prepared 433 plants from which 2809 pumpkins were harvested.6 In an interview with with Nirmal Bepary, a Bangladesh water ambassador and Practical Action representative, Mohammed says: “The opportunity and the technology is a blessing for us, it has opened our eyes to see a better life and a new hope to live.”1 Another situation where Practical Action had a great effect was with the 2016 flood in the district of Kurigram that left 2,500 individuals in critical need of food, water, and first-aid.5 The event summoned Practical Action’s emergency response team, who sprang into action to assist families endangered by the flood. But sandbar cropping alone was not the only key player in mitigating the disaster–––intercommunal cooperation was critical. Neighboring communities showed an awe-inspiring commitment to helping the flood victims. Some families traveled nearly forty kilometers to come to afflicted areas, sympathizing with those affected because they too had suffered similar damages from unpredictable flooding. Within the hour of the emergency response call, hundreds of households happily volunteered to assist neighboring communities, donating their time, services, and pumpkins to help crop the sandbar lands with five metric tons of pumpkins, thus resettling the victims with more secure and sustainable food sources.5

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The opportunity and the technology is a blessing for us, it has opened our eyes to see a better life and a new hope to live.

”

Saiful’s story of recovery and the rebuilding of Kurigram are illustrations of a broad reality that underprivileged communities would rather adapt and stay in their environments than move away from their homes. Practical Action (in addition to feeding stomachs) is helping to drive socio-economic change for these families. By working with the UK Government in the join 1.1 million dollar Pumpkins Against Poverty project, the organization has helped spread knowledge in the communities about formal market structures and price margins.7 Using these economic guidelines as mercantile tools, Bangladeshi families have begun producing crops not only for food, but for profit: around

1,000 pumpkins are sold per family (80% of their harvest) with an average of 5 to 1 return on investment.5, 7 Sandbar cropping has so far helped tens of thousands of farmers to transform thousands of acres of mini-deserts into plentiful fields of crops.5 Right now, sandbar cropping generates 9,000 meals daily in Bangladesh communities alone, and in total, it has contributed to the growth of 98,000 tons (~$10 million worth) of pumpkins.2, 7 Practical Action is currently doing field tests in India and Nepal, whose yearround growing climates will help diversify crops and create a sustainable market. The goal is to expand the ‘justice technology’ beyond Bangladesh, to other countries around the world. www

Minh Vu is a freshman in Silliman College majoring in English and Molecular, Cellular & Developmental Biology. Contact him at minh.vu@yale.edu.

Bangladeshi woman holding a newly harvested pumpkin.

Securing Water For Food

VOLUME 4, NO.2

GLOBAL HEALTH TODAY

Strange Ways:

What Virus Evolution Can Tell Us About The Next Epidemic By Colin Hemez

n mid-November of 2002, a few farmers in the Guangdong province of China began falling ill with pneumonia-like symptoms. This was not necessarily out of the ordinary for the region, but the disease spread rapidly, infecting some 806 people and killing 34 by mid-February of 2003.1 A doctor from Guangdong who had treated some of these mysterious cases traveled to nearby Hong Kong on February 21, 2003 for a wedding. Four days before, a 33-yearold man staying with his brother in Block E of the massive Amoy Gardens housing complex in Hong Kong died of unknown causes. Within a few weeks, 329 residents of Amoy Gardens became infected (42 of whom died), in addition to numerous individuals who had stayed on the same hotel floor as the Guangdong doctor in late February.2 These hotel patrons—who by now had returned to their homes in Taiwan, Vietnam, Canada, and a number of other countries—carried with them a disease that would have the potential to cause a worldwide epidemic. By the time the World Health Organization declared that the outbreak was contained on July 5, 2003, the severe acute respiratory syndrome coronavirus (SARS-CoV) had infected 8273 people, killed 775, and cost an estimated US $40 billion in economic losses throughout the world.3 SARS-CoV, belonging to the same family of viruses that cause the common cold, likely emerged in Guangdong animal markets, where bats, Himalayan palm civets, and people—each

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As long as there are cells, there will be viruses that are continually evolved to infect them.

”

of which is a natural reservoir for a member of the coronavirus family—interacted in close quarters with one another.4

not well understood, while horizontal gene transfer may play an important role in the virus’s interactions with the host.

What caused SARS-CoV to evolve at the time that it did? Why was it so virulent, when its cousin—the common cold—causes nothing more than a runny nose and a sore throat in the vast majority of cases? Researchers still do not know the full answer, but beginning to answer this question requires an understanding of how and why viruses evolve. Viruses’ evolutionary patterns are unique among biological entities because they are non-living. In fact, viruses do not evolve; they evolve through the cells they infect, dependent on the replication machinery of their hosts to transmit their genes on to the next generation. The evolutionary origins of viruses is also unique among biological systems and is hotly debated among researchers today. Regardless of their evolutionary origins, however, viruses evolve by two major mechanisms: mutation during genome replication and horizontal gene transfer, a phenomenon by which genetic information is exchanged from one existing virus (or host cell) to another existing virus, rather than being transmitted from one generation to the next. Mutation rates vary considerably among virus species for reasons that are

In any case, as for all biological entities that interact with other organisms—whether living or not, and regardless of how they evolved in the first place—the evolutionary story of viruses is one of tradeoffs and checks and balances, that limit what is possible for viruses to do. In other words, viruses have many tricks up their sleeves, but we might be able to predict what they will do next by having a solid understanding of these tradeoffs. All of this understanding, in addition to shedding light on the weird and fabulous world of viral biology, will be crucial for predicting future viral epidemics and formulating public health interventions that anticipate those events. DO VIRUSES EVEN EVOLVE? In common parlance—and even among most virologists—it is common to discuss viruses as organisms that evolve just like cats, dogs, plants, people, archaea, and bacteria. And this is for good reason: epidemiologists want to understand the pressures of natural selection that might cause the influenza virus to hop hosts from birds to humans, or that might cause the Zika virus

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NIAID

False-color micrographs of various coronaviruses, including the viruses for severe acute respiratory syndrome (SARS-CoV) and middle east respiratory syndrome (MERS-CoV). These viruses are roughly spherical, and display a characteristic “crown” of proteins that decorate the surfaces of the virus particles.

Gregorius Pilosus

Whereas vertical gene transmission (right) occurs by passing genes from one generation of cells onto another, horizontal gene transfer (HGT, left) takes place when an existing cell or virus acquires DNA (red squiggle) from another source. HGT allows biological entities to acquire potentially useful genes that don’t already exist in their genome.

VOLUME 4, NO.2

to become more virulent. But this kind of vocabulary overlooks an important aspect of viruses that informs their evolution: viruses are not alive. The definition of life is an unresolved question, but most contemporary researchers agree that living organisms must be metabolically active—that is, they can eat and convert energy from one form to another. They must also be capable of reproducing themselves. The basic unit of life, then, is the cell, which includes bacteria, plant, and animal cells. Viruses are not like living cells. They are not metabolically active; they do not consume energy. Because of this, they are only capable of reproducing themselves using the replication machinery of living cells, be they bacteria, plant cells, or human cells (all of which are susceptible to viral infection). The fact that viruses are non-living has profound implications on the way they evolve; without living cells to copy the virus’s own genetic information and generate new virus particles, the virus itself could not evolve.5 This means that viral genomes change over time because the cells that viruses infect have some incentive to mutate the viral genome. This incentive, of course, is for the cell to avoid becoming infected. Thus as long as there are cells, there will be viruses that are continually evolved to infect them. WHERE DO VIRUSES COME FROM? If viruses were truly living, as are plants and people and bacteria and other living cells, all viruses that exist today would have been derived from a single common ancestor. Just as an early cell, some three and a half billion years ago, gave rise to all living organisms that exist today, an early virus would have given rise to all the viral species that we now find on the planet. In support of this theory, viral capsids—the molecular envelopes that package the virus’s genetic material—take on a remarkably small number of shapes.6 This suggests that capsid shape is a trait that has been passed on from virus generation to generation—with little variation—since the earliest evolutionary times. However, an opposing theory suggests that new viral species can emerge not just by evolution from a single ancestor, but also by “gene escape” events in which the right collection of genes escapes a living cell, acquires a molecular envelope, and transforms itself into a virus that can infect

living organisms. Indeed, such an event is thought to have spawned the human Hepatitis Delta Virus, formed when a DNA sequence coding for a molecule called a ribozyme jumped ship from the human genome and eventually became part of a virus.7

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Researchers need to better understand how new virus species can form from the genetic material that already exists in living cells.

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So which is it: were viruses all evolved by living cells from a common ancestor, just like plants and animals, or do they arise spontaneously as a result of gene escape events? In fact, both theories are probably true. It would be unreasonable to posit that virus families do not have some kind of lineage as do living cells (otherwise, how would we know that SARS-CoV is related to the common cold virus?), but not impossible to propose that each of those families arose as a result of independent gene escape events. Because of this dual origin of viruses, researchers and public health actors need to take a two-pronged approach to predicting and managing viral epidemics. Known human viruses need to be closely monitored lest they emerge unexpectedly, while researchers need to better understand how new virus species can form from the genetic material that already exists in living cells. Public health actors cannot discount the possibility that, even with all the possible interventions in place to combat known viruses, new viral species could emerge as a result of these mechanisms. MAKING MISTAKES Perhaps because they hijack the machinery of living cells to replicate their own genomes, viruses change their genomes using mechanisms that are identical to those in cells. The two major mechanisms by which viruses acquire changes in their genomes are mutations that arise during DNA replication and horizontal gene transfer. Every living organism must make copies of its genome to reproduce, and so every living organism has genome replication machinery to carry out this task. Viruses reproduce by hacking these rep-

lication machines to produce not the host cell’s genome, but the virus’s own genome. Some viruses even have their own replication machinery encoded within their genome, but they still rely on the host cell’s protein building machinery to build those replication machines. Any copying process is subject to error, and it is this error-prone copying process that allows viruses to acquire mutations in their genomes that might give them an advantage over other virus particles, driving natural selection and evolution. Different types of viruses have different mutation rates: Viruses that use DNA as their genetic material have error rates that are often on par with their DNA-replicating hosts. Viruses that use RNA—a molecule very similar to DNA—as their genetic material have error rates anywhere from 100 to 10,000 times higher than that of DNA viruses.8 Another way that viruses can change their genomes is through a mechanism known as horizontal gene transfer (HGT), which involves moving a chunk of genetic material from one biological entity to another, rather than replicating the chunk. Far from unique to viruses, HGT is an important feature in the evolution of bacteria (including those that cause tuberculosis and most infections that take place during surgery), which often exchange antibiotic resistance genes through HGT to resist getting killed by medicines.9 Viruses can engage in HGT as both the recipients of a gene from a living organism, or as donors of a gene to a living cell (indeed, viral infection itself is a form of HGT). They can also engage in HGT events that take place between two viruses. In bacteria, HGT can mediate the rapid spread of antibiotic resistance genes across diverse bacterial species, rendering most antibiotics useless for treating disease within three or four years of their introduction in the market. HGT in viruses is less well understood, but it is easy to imagine that genes that play a role in virulence or host range could rapidly spread across virus populations if sufficient evolutionary pressure was placed on them to do so. When developing new treatments for viral diseases, then, researchers need to be mindful of how viruses could circumvent those treatments. If a virus were to develop resistance to the treatment via mutations during replication, it might be able to rapidly disseminate that resistance gene to other viruses within the body of a patient who is undergoing treatment.

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Course of

In the 2002-2003 SARS epidemic

8273 people were infected and

775 people

SARS infection:

10 day latency period, 7 day disease period,

The economic cost of the 2002-2003 SARS epidemic was over

$40 billion.

usually followed by pneumonia.

were killed.

CONSTRAINED BY TRADEOFFS Despite being error-prone, non-living biological entities that are evolved by the cells they infect, viruses follow exactly the same rules of evolution as other living organisms; this means that their evolution is a history of tradeoffs. Because of genetic or environmental constraints, the evolution of one trait in an organism is often linked with the evolution of another. The basis for these tradeoffs is genetic: often, one gene has multiple functions, and variations of that gene that make it better at performing one function will most likely make it worse at performing another function.

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Tradeoffs limit the range of possibilities for the evolution of viruses (or any organism, for that matter). Even if a virus could acquire a gene that significantly increases virulence in humans by HGT, there is no guarantee that this virus would rapidly begin to spread and start an epidemic, since the gene might be involved in a tradeoff that affects the virus’s ability to perform other essential functions. Just as tradeoffs affect a virus’s balance between carrying out its essential functions and infecting new hosts, they also influence our ability to control virus spread through vaccination. The so-called “imperfect vaccines,” which provide only par-

Because of genetic or environmental constraints, the evolution of one trait in an organism is often linked with the evolution of another.

One of the major tradeoffs which dictates the evolution of viruses is the virulence-transmission tradeoff. Viruses that are more virulent—that is, that can produce more viral particles at the expense of the host’s health and chance of survival—are less capable of transmitting to another host. This is because viruses that kill their hosts more rapidly give less of an opportunity to the host to interact with other uninfected individuals, and thus transmit the virus. 10 Another tradeoff that exists between viruses involves virulence and host range. Viruses that can infect a greater number of host species are less effective at reproducing in any one of them, since they must maintain a diverse arsenal of cell receptors and immune evasion strategies for each host.

VOLUME 4, NO.2

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tial coverage against a pathogen, select for increased virulence by forcing viruses to evolve more aggressive infection cycles to combat the partial immunization. That is, such vaccines can afford to be on the more virulent side of the virulence-transmission tradeoff because increased virulence does not lead to less efficient transmission in partially immunized people. This may not affect those who are already immunized, but it means that the pathogen will be more aggressive—and thus more likely to kill—in individuals who are not immunized.11 As researchers develop new imperfect vaccines for viral diseases, public health actors need to carefully manage the deployment of these interventions. By and large, even imperfect vaccines—whether against viruses, bacteria, or multicellular parasites—should be used frequently be-

cause they greatly reduce the prevalence of disease (as has been the case with the partial malaria vaccine), but officials will benefit from considering the long-term evolutionary consequences of these interventions.12 So what caused SARS-CoV to emerge when it did, and to kill as effectively as it did? It will be very difficult (maybe even impossible) to know for sure, but the unique evolutionary story of viruses certainly played a role. Derived from other coronaviruses, SARS-CoV might have arisen as a result of HGT between existing viral species, and could have been evolved further by acquiring mutations through replication in its reservoir population (likely bats) before infecting humans. This unique genetic makeup placed SARS-CoV in a dangerous place on the virulence-transmission tradeoff with regards to human infection, since highly virulent pathogens can more easily spread throughout the increasingly interconnected human population. These factors—genetic mutation, horizontal gene transfer, evolutionary tradeoffs, human connections—are factors of life itself, and are sure to drive the evolution of viruses in the future. An awareness of the mechanisms through which viruses evolve is crucial to keeping the world’s population healthy and safe in the dynamic balance between cell and virus evolution. www Colin Hemez is a junior in Ezra Stiles College majoring in biomedical engineering and art history. Colin is originally from Los Alamos, New Mexico. He can be contacted at colin.hemez@yale.edu

Pixabay

HEALTH POLICY

Healthcare: Is there only one correct answer? T

By Elizabeth Li

he United States (US) healthcare system and the European healthcare system are ideologically and functionally different. When it comes to rankings, the US consistently ranks below other countries, such as France, Germany, and the United Kingdom in terms of life expectancy and health-care spending per capita. This disparity in the rankings begs the question: is the European healthcare system better than the US healthcare system? Not only are our healthcare systems different, but the medical training timeline also differs. Could variations even in the way doctors are trained be affecting the overall quality of a country’s healthcare? In order to understand why this disparity might exist, I traveled to three European countries to gain a human perspective on how the European system works and how its differences from the US system affect people’s health. EUROPEAN HEALTHCARE In the European Union, most countries have two kinds of hospitals: those that belong to the private sector and those that are part of the public sector. Hospitals in the private sector are normally not subsidized by the government while public hospitals, which make up the majority of hospitals in Europe, are mostly funded by the government. The government is able to fund public hospitals because citizens pay a separate healthcare tax in addition to the income tax. For example, in Lithuania, people pay a nine percent health tax.

Although most countries follow this system, there are still major differences when it comes to how the population pays for treatment and how people are reimbursed at public hospitals. In France, patients pay for their treatment upfront using a “carte vitale,” a health insurance card, and the state reimburses all or most of the cost within a few days. However, even with the reimbursement, it is common for people to also purchase their own insurance in order to ensure that they are reimbursed 100%. Notably, in Belgium, which follows a healthcare system similar to that of France, alternative treatments such as acupuncture and chiropractic care performed by a qualified doctor also qualify for reimbursement through the government. The majority of the French and Belgian population go to government-funded hospitals for treatment. On the other hand, in Germany, a larger percentage of the population get private insurance. The people who turn to private insurance are usually younger; their premiums cost less because they are theoretically healthier and at less of a health risk than the elderly. Unemployed people or people who earn less than a relatively high threshold are also funded through non-profit organizations. Finally, the European Union also offers the European Health Insurance Card. This free card allows European citizens to receive medical treatment in emergencies or for preexisting conditions in other countries in the union for free or at a discounted price. Ultimately, because most countries in Europe have universal healthcare, citizens are able to obtain treatment more or less free of charge wherever they travel within Europe.

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EUROPEAN MEDICAL TRAINING/ PROFESSION In terms of medical education, European students follow a timeline that allows them to complete all of their medical training (school and residency) in seven to ten years after graduating high school. Different countries have different methods of admitting students into medical school, but all European schools share one thing in common: European students do not earn a bachelor’s degree before applying for medical school. In other words, they progress straight from high school to medical school, which usually lasts six years. Although the overall education timeline is relatively standardized, certain variations also exist. For example, in France, any high school student may enroll in the first year of medical school. However, in order to proceed to the second year, they must complete an exam at the end of the first year and rank in the top percent of the class. Furthermore, medical schools have different qualifications in different countries. According to the Journal of Ethics, medical school admissions officers in most European countries—Greece, Italy, Spain, etc.— “use exclusively academic criteria to select students for the majority of seats available in medical schools.” They look at a combined score of student’s high school GPA and national biology, physics, and chemistry exam scores in order to determine their qualification. However, other regions such as the United Kingdom look at applications on a more holistic level, taking both academic strength and extracurricular activities into consideration. Similarly, different countries have different methods of placing medical students into residencies. In most countries, there actually is no examination required for admission into a res-

ident program or specialty. Only a few countries, including France, Portugal, and Spain, require medical school graduates to take a national exam first before choosing a specialty. Ultimately, just like their healthcare system, European medical schools follow the same general medical timeline, but slight variations between countries also exist.

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Despite the fundamental differences that exist between the US and European healthcare systems, each system could benefit from adopting practices of the other

US HEALTHCARE

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In contrast to the European healthcare system, the US healthcare system operates mainly through privately-owned facilities, also known as private sector businesses. On a very basic and simplified level, there are essentially three components: the providers, the population, and the insurers. Included in providers are the doctors, nurses, and any other hospital staff who provide healthcare. The population refers to anyone in society who seeks medical attention, whether that be a treatment for a chronic illness, a visit to the hospital for a routine checkup, or simply just to ask a question. Lastly, insurers, as the name implies, mainly

consists of insurance companies. There are two ways for the people of the population to obtain insurance: either they pay for their own premium—i.e. their insurance policy— or their employer includes their insurance as a part of their job’s health benefits. Providers receive most of the payment from these insurers. However, insurance companies usually also require the population to pay providers a copay—a small amount out of pocket—for each visit in order to discourage people from visiting the hospital when they do not really need to. For those who are unable to afford the copay or the insurance—whether that is because they are unemployed or are unable to pay for their own premium, social programs attempt to provide health insurance for these families. The largest of these programs is Medicaid, funded by the state and federal government. In addition, laws have also been passed in order to help more people obtain insurance. For example, the Patient Protection and Affordable Care Act (PPACA), commonly known as Obamacare, passed in 2010 has largely increased the number of individuals who can afford healthcare by increasing health insurance quality but decreasing the cost. Specifically, it is now required for all insurance companies to accept a patient regardless of his or her pre-existing conditions. This is especially helpful for people who may have pre-existing conditions or a family history of a disease because it prevents insurance companies from denying these patients insurance or charging an insanely high premium. Unfortunately, in the US, there is also a social stereotype that public health insurance subsidized by the government is considered “welfare for lazy people” while private health insurance is considered inaccessible. Furthermore, the system is becoming increasingly politicized as different political parties argue for an increase or decrease in taxes. Flickr

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US MEDICAL TRAINING/PROFESSION As for medical training, in the US, after high school, it takes anywhere from 11 to 15 years to complete one’s education as a doctor. The timeline begins after high school, extending from undergraduate college/university to medical school and finally to residency. As an undergraduate, students are exposed to a broad spectrum of subjects in both the humanities and the sciences. During their undergraduate years, those interested in applying for medical school must build an application consisting of a strong grade point average (GPA), a variety of extracurricular activities, and a high Medical College Admissions Test (MCAT) score, an exam taken toward the end of college. If accepted, students continue with another four years of education in medical school. During these formative years, students often learn the core principles of medicine (from books) before completing rotations (in clinics) in their third and fourth years. Although the timeline described above is most common, some variations also exist. For example, it is becoming increasingly common for people to take gap year(s) between undergraduate and medical school. According to US News, students on average begin medical school when they are 24 years old even though most earn a bachelor’s degree by the time they are 22 years old. After completing medical school and receiving their Doctor of Medicine degrees (MD), students apply to residency programs and, if they are matched with a program, move on to their last stage of medical training. Depending on what specialty students apply for, residencies can last for as little as three years (e.g. family practice) or as long as seven years (e.g. plastic surgery). At this point, even though they are still technically learning more clinical skills, residents are considered to be employed since they are paid a salary, although not very high. Finally, after completing all these steps, students finally formally complete their medical education. Although there is a wide range of salaries depending on several factors, such as a doctor’s specialty, location, and hiring hospital, doctors tend to earn a minimum of around $130,000. In the US, doctors are generally well-respected and well-paid. METHODOLOGY However, these data do not capture the full nuance of how each health system works because these data lack human perspective. Therefore, I traveled abroad this summer to

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several different countries, including Lithuania, Greece, and Portugal, to find out more about European healthcare and medical training from the people who comprise the healthcare system itself. Part of the time I was abroad, I shadowed doctors in a variety of departments and also managed to interview the hospital staff in various positions. In Vilnius, Lithuania, I interviewed Dr. Sarkinus, a pediatric surgeon. In Athens, Greece, I interviewed Stavros Tsitiridis, a spring nurse working in the cardiac surgery department of Evangelismos Hospital. And lastly, in Terceira, Portugal, I interviewed Rui Duarte Gonçalves Luis, president of the administrative board of Hospital de Santo Espírito. Interviews took place either in the interviewee’s office or in the operation room before a procedure and lasted for approximately half an hour. In each interview, I centered my questions around three topics: the country’s healthcare system, the country’s medical training timeline, and each respondent’s personal story of how they became a doctor. In the first section, participants described their country’s healthcare system, listed the most prominent strengths and weaknesses of their national system, and commented on the differences—including which system they found superior—between European and US healthcare. Similarly, in the second section, participants described, listed, and commented on the education process for becoming

a doctor in their country. The third section sought to shed light on one question, “How did you know you wanted to work in medicine?”

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According to US News, students on average begin medical school when they are 24 years old even though most earn a bachelor’s degree by the time they are 22 years old

HUMAN PERSPECTIVES ON HEALTHCARE

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When asked about healthcare, the three interviewees had varying opinions. Tsitiridis from Athens believed that making Greece’s healthcare system more privatized would not be beneficial, as hospitals would then no longer have the incentive to accept patients without social security. The way the Greek system currently is set up, theoretically

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everyone pays for social security and in turn, everyone is able to be hospitalized. However, in reality, many people do not have social security, either because they cannot afford it or do not have a high enough salary. As a result, those who do pay for social are also affected since the taxes they pay must cover not only their own treatment but also the treatment of those who do not have social security. Essentially, Greece has to use the taxes collected from a proportion of the population to support the entire population. This leads to shortages of basic supplies in hospitals and the inability to develop new techniques. In fact, in Greece I witnessed a mitral valve replacement surgery that was done via open heart surgery and involved temporarily stopping the heart and circulating the blood through a heart-lung machine. In the US, due to more advanced technology, most mitral valve replacements are able to be completed simply through a series of small incisions, significantly decreasing recovery time and the chance of infections and other complications. On the other hand, President Gonçalves Luis from Terceira had mixed feelings about both the European and the US healthcare system. He stated that the biggest hardship hospitals face is the lack of funding from the government. According to Gonçalves Luis, “the difference between private and public [hospitals] is that normally [private hospitals are more efficient].” In other words, people who work in public hospitals are less concerned about saving resources and using them wisely. Gonçalves Luis attributes this behavior to the fact that because public hospitals are not making a direct profit, administrators and employees care less when it comes to how much people use. “If we had another system, like the US, maybe people will [only] go to the hospital when they really need to,” implying that checkups and thus materials are often used in excess. Furthermore, at the time I was visiting, nurses in the Azores islands—which Terceira is a part of—were striking due to inconsistencies in the number of work hours per week. Gonçalves Luis explained that in the public sector, nurses work 35 hours a week while in the private sector, nurses work 40 hours a week. However, public hospitals in the Azores are starting to become what is known as a “public company,” which means they still belong to the government but must follow private sector rules. During this period of transition, nurses who were hired before the change still work 35 hours, but any nurses newly hired now must work 40 hours. This discrepancy resulted in riots as

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all nurses, old and new alike, demanded to work the same number of hours per week. This situation occurred because the European healthcare system is comprised of both a strong public and a strong private sector. In agreement with President Gonçalves Luis from Terceira, Dr. Sarkinus in Vilnius believes that there is no such thing as a better system. All patients know that their treatment will be paid for, even if they cannot pay for it themselves. Consequently, Lithuania faces a problem with people coming to the hospital for very minor treatments that could have been taken care of at home. According to Dr. Sarkinus, “I think the best is [a mix of both healthcare systems]; you pay as a tax, for example for emergency help, and then the insurance comes in later.”

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Although there is a wide range of salaries depending on several factors, such as a doctor’s specialty, location, and hiring hospital, doctors tend to earn a minimum of around $130,000.

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SECOND QUESTION: MEDICAL TRAINING

As for medical training, all three interviewees agreed that people become doctors in Europe and the US in roughly the same timeframe, despite differences in education timelines. US doctors who do not take gap years or complete alternative programs earn their MD at the earliest age of 29. In Europe, doctors can earn their degrees by the time they are 27. To make things even faster, Dr. Sarkinus believes that medical school in Europe could be even shorter. In his experience, “the last two years in [medical school] were actually a waste of time […] lots of people [have more time and] start entering their second specialties—for example chemistry, math, law, etc—during those years. This means that the studies can be a little shorter at the university and you can save a year or so.” Ultimately, because students in Europe do not attend undergraduate for four years, they earn their degrees a little earlier, but not much. This minute difference in age seems

to be inconsequential and likely does not significantly affect their performance as a physician. THIRD QUESTION: SOCIAL ISSUES Only Dr. Sarkinus in Vilnius shared why he became a doctor. Dr. Sarkinus says his family and society’s stereotypes had a big influence on his decision to become a doctor. “My aunt, she told me that if you are a doctor, you will be respected for your entire life and that it’s a good specialty. You always will have work and you can live and have money. But I was fooled because it is not like that.” At least in Lithuania, being a doctor does not guarantee financial stability. As a pediatric surgeon with ten years of experience, Dr. Sarkinus says he earns 800 Euros, approximately 870 USD, a month after all taxes are accounted for. In comparison, pediatric surgeons in the US earn up to 40,000 USD a month. “In the normal world, everywhere it’s different; all of the doctors, teachers, policemen, firemen, they all get very well paid. But it’s not like that in Lithuania,” says Dr. Sarkinus. In fact, people in each country I traveled to shared a common belief that doctors are underpaid. CONCLUSION Ultimately, it does not seem like one healthcare system is decisively better than the other. In addition, the different styles of training doctors do not seem to be play a role in the different problems that the US and European healthcare systems face. Despite the fundamental differences that exist between the US and European healthcare systems, each system could benefit from adopting practices of the other. In other words, each system must improve, but in different ways. Crafting a flawless healthcare system is immensely complex, but one place to start could be by incorporating elements of the “opposite” healthcare system. Finding the perfect balance between the public and private healthcare may very well be the resolution to the issues faced by both systems.

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Elizabeth Li is a sophomore in Morse college majoring in Molecular, Cellular, and Developmental Biology. Contact her at elizabeth.li@yale.edu.

HEALTH PERSPECTIVES

CHINA:

A Spoonful of Sugar Helps the Medicine Fight Cancer By Gracie Jin

n September, a team of researchers at the Johns Hopkins School of Medicine discovered that the addition of glucose, a simple sugar, could transform a plant extract into a drug with potentially anti-cancer effects. To put it another way, Mary Poppin’s age-old lyric “a spoonful of sugar helps the medicine go down” became, albeit metaphorically, a biomedical reality. The researchers’ findings were published in the German Chemical Society journal Angewandte Chemie, offering a promising bridge between eastern and western medicine. The story begins in 1993 when Jun Liu, professor of Pharmacology and Molecular Biology at Johns Hopkins, spotted an advertisement while attending a conference in China: “I walked out of my hotel, and there was this billboard advertising an extract from the thunder god vine as a novel immunosuppressant. I was already working on two immunosuppressive drugs isolated from microbes, so this piqued my interest.”

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Thunder god vine has a 400-year history in traditional Chinese medicine and was used to calm overactive immune responses in conditions such as rheumatoid arthritis and multiple sclerosis. Its active ingredient, Triptolide, is not a novel molecule; its mechanism of halting cell growth had been well documented. Five years ago, Liu and colleagues found that triptolide kills cancer cells in vitro by irreversibly inhibiting a protein known as XPB, which is involved in RNA synthesis and DNA repair. However, the molecule’s anti-cancer capability does not extend well beyond the laboratory. Its ineffectiveness in humans is mainly due to two limitations: first, triptolide does not dissolve adequately in water or blood, which makes the drug difficult to administer. Second, the its killing mechanism does

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not distinguish between healthy cells and tumorous cells, which leads to toxic side effects. To tackle these limitations and make Triptolide a viable form of chemotherapy, three research groups joined forces across continents—–Liu, from Johns Hopkins, his colleague Pomper (also from JHU), and Yu from the Chinese Academy of Sciences. “We were looking for something that could be administered intravenously, remain stable in the blood and then become active as soon as it was imported into cancer cells,” says Liu. The team of scientists started their research with the knowledge that most cancer cells overproduce glucose transporters, which allows the cancerous cells to absorb maximum amounts of glucose to use as energy to reproduce. Liu’s team hypothesized that attaching glucose to triptolide would trick the cancer cells into thinking that the triptolide was actually sugar, causing them to absorb the toxin and die. To test their theory, the chemists first synthesized five derivatives of triptolide, each with glucose inserted the same spot, but attached with different “linkers.” When these five “glutriptolides” were tested in human embryonic kidney cells, glutriptolide 2 won the race: it reduced the cancer cells’ uncontrolled replication more effectively than all the rest. The next part of the study was to compare glutriptolide 2 to triptolide, to see if the former was really better at targeting cancerous cells. The researchers found that while triptolide targeted cell growth in both cancer and healthy cells without selectiveness, the glucose-enhanced glutriptolide 2 was 8 times more likely to attack cancer cells vs. healthy cells. According to Liu, “the new compound is quite water soluble, it prefers cancer cells over healthy cells and could therefore have fewer side effects.” So, Mary Poppins was right. A spoonful of sugar does help the medicine go down, or at least makes it more effective. But every new drug has risks: how toxic, exactly, is the man-made glutriptolide? Is it safe to digest? Will it destroy healthy human tissue? While these questions require further research, laboratory tests on mice show positive results. Mice can tolerate a dose of glutriptolide 5 times higher than triptolide,

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Johns Hopkins

all the while eradicating prostate cancer tumors faster and resisting recurrence for 3 weeks. Dr. Liu expressed “[total surprise] to see that sustained antitumor activity.” Exciting research is currently underway to tweak the links between triptolide and glucose to maximize cancer cell-killing and minimize healthy cell-killing. Dr. Liu’s company Rapafusyn Pharmaceuticals Incorporated, of which he is a co-founder and board member, has a nondisclosure agreement with Johns Hopkins University regarding their research on triptolide. “Right now, we think of triptolide as the explosives you pack into a missile. It’s too toxic to be let loose,” Dr. Liu explains. The researchers do not want their work with triptolide to be applied in potentially dangerous settings. “So we’re engineering a ‘missile head’ for it,” says Dr. Liu, “to direct it solely to cancer cells. We should know in a few years’ time if it works.” Dr. Liu is part of an ongoing effort to bring two symbiotic eastern and western systems of medicine closer together. Another scientist with a similar endeavor named Dr. Youyou Tu received the 2015 Nobel Prize in Physiology or Medicine for discovering the malaria drug artemisinin in the extracts of an ancient medicinal plant, Artemisia annua. Yet another leader in traditional Chinese medicine research, Yale professor Dr. Yung-Chi Cheng, is developing a four-herb combination called PHY906 to reduce chemotherapy side effects in colon cancer. Dr. Cheng also serves as chairman of the Consortium for the Glo-

balization of Chinese Medicine, a nonprofit aiming to widen the benefits of Chinese herbal medicine globally. These scientists’ work shed valuable light on modern global health. As Johns Hopkins history of medicine professor Marta Hanson puts it, researchers like Liu and Tu are “medically bilingual” —fluent in not only two languages, but also the complex nuances of two contrasting worlds of medicine. While some believe traditional Chinese medicine to be bogus and arcane, Chinese medical therapies are still in demand around the world. They meet the needs of patients who either culturally feel more comfortable with them or are dissatisfied with what Western medicine is able to provide. Hanson describes traditional Chinese medicine as a mirror that reflects both the strengths and shortcomings of western medicine, therefore offering it routes through which to grow. A synergistic integration between holistic approaches and evidence-based treatment would benefit all hemispheres of the globe. Each sweet discovery is a taste of more exciting developments that lie ahead.

www Gracie Jin is a freshman in Berkeley College interested in studying neuroscience and global health. She can be contacted at grace.jin@yale.edu.

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